| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $15 | $24 | $37 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $12 | $17 | $29 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $9 | $22 | $46 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $8 | $34 | $71 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $7 | $21 | $57 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $29 | $40 | $52 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $44 | $188 | $380 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $33 | $204 | $403 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $11 | $62 | $118 |
| Special stain group II CPT 88313 • Pathology | $3 | $29 | $95 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $27 | $51 | $66 |
| Frozen section pathology each additional CPT 88332 • Pathology | $6 | $21 | $33 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $25 | $46 | $89 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $25 | $53 | $97 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $30 | $64 | $113 |
| Microdissection manual CPT 88381 • Pathology | $43 | $134 | $246 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $7 | $12 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $14 | $19 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $14 | $17 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $16 | $21 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $16 | $20 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $29 | $35 | $42 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $19 | $36 | $48 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $18 | $31 | $42 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $17 | $30 | $38 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $11 | $20 | $25 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $39 | $99 | $139 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $50 | $102 | $139 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $50 | $102 | $139 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $19 | $65 | $95 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $16 | $37 | $54 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $31 | $39 | $46 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $28 | $45 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $20 | $29 | $47 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $33 | $50 | $69 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $20 | $35 | $58 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $13 | $21 | $31 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $6 | $10 | $12 |
| Immunization admin injection single CPT 90471 • Preventive Care | $19 | $23 | $27 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $8 | $13 | $20 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $210 | $405 | $651 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $156 | $269 | $364 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $68 | $127 | $203 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $14 | $25 | $39 |
| MMR vaccine CPT 90707 • Preventive Care | $65 | $120 | $194 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $33 | $50 | $58 |
| Varicella vaccine CPT 90716 • Preventive Care | $125 | $237 | $380 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $120 | $144 | $188 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $220 | $285 | $426 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $99 | $127 | $153 |