| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $7 | $27 | $57 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $19 | $52 | $73 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $55 | $79 | $125 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $44 | $236 | $479 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $112 | $335 | $714 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $15 | $57 | $117 |
| Special stain group II CPT 88313 • Pathology | $12 | $53 | $100 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $27 | $77 | $111 |
| Frozen section pathology each additional CPT 88332 • Pathology | $13 | $47 | $91 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $23 | $56 | $98 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $40 | $65 | $120 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $20 | $74 | $145 |
| Microdissection manual CPT 88381 • Pathology | $37 | $126 | $254 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $6 | $9 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $15 | $21 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $11 | $16 | $20 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $18 | $24 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $15 | $24 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $33 | $49 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $22 | $35 | $54 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $17 | $30 | $49 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $21 | $31 | $46 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $13 | $20 | $30 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $58 | $101 | $166 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $75 | $105 | $166 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $105 | $166 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $28 | $79 | $128 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $18 | $35 | $59 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $36 | $54 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $22 | $34 | $52 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $23 | $36 | $57 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $42 | $78 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $23 | $38 | $69 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $7 | $25 | $38 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $11 | $15 |
| Immunization admin injection single CPT 90471 • Preventive Care | $7 | $21 | $34 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $5 | $12 | $24 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $314 | $333 | $351 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $290 | $387 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $101 | $106 | $113 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $23 | $27 |
| MMR vaccine CPT 90707 • Preventive Care | $65 | $90 | $108 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $44 | $49 | $55 |
| Varicella vaccine CPT 90716 • Preventive Care | $112 | $169 | $208 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $52 | $113 | $147 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $220 | $228 | $246 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $75 | $91 | $114 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $89 | $129 | $188 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $89 | $130 | $195 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $100 | $144 | $219 |