| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $67 | $77 | $87 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $33 | $33 | $33 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $91 | $145 | $200 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $240 | $414 | $588 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $835 | $1,047 | $1,259 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $186 | $186 | $186 |
| Special stain group II CPT 88313 • Pathology | $183 | $183 | $183 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $104 | $142 | $180 |
| Frozen section pathology each additional CPT 88332 • Pathology | $36 | $63 | $89 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $61 | $92 | $122 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $144 | $195 | $246 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $370 | $370 | $370 |
| Microdissection manual CPT 88381 • Pathology | $73 | $204 | $336 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $11 | $11 | $11 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $10 | $10 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $12 | $12 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $12 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $25 | $25 | $25 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $29 | $29 | $29 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $25 | $25 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $23 | $23 | $23 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $15 | $15 | $15 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $147 | $147 | $147 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $84 | $84 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $84 | $84 | $84 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $97 | $97 | $97 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $32 | $32 | $32 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $28 | $28 | $28 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $27 | $27 | $27 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $28 | $28 | $28 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $41 | $41 | $41 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $35 | $35 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $16 | $16 | $16 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $12 | $12 | $12 |
| Immunization admin injection single CPT 90471 • Preventive Care | $16 | $16 | $16 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $12 | $12 | $12 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $369 | $369 | $369 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $254 | $254 | $254 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $115 | $115 | $115 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $22 | $22 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $107 | $107 | $107 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $55 | $55 | $55 |
| Varicella vaccine CPT 90716 • Preventive Care | $215 | $215 | $215 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $131 | $131 | $131 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $241 | $241 | $241 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $234 | $234 | $234 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $245 | $245 | $245 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $255 | $255 | $255 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $286 | $286 | $286 |