| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $45 | $180 | $327 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $34 | $218 | $490 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $4 | $61 | $127 |
| Special stain group II CPT 88313 • Pathology | $8 | $37 | $93 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $27 | $73 | $117 |
| Frozen section pathology each additional CPT 88332 • Pathology | $8 | $36 | $63 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $26 | $71 | $110 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $61 | $128 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $20 | $74 | $136 |
| Microdissection manual CPT 88381 • Pathology | $20 | $98 | $220 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $3 | $4 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $11 | $13 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $12 | $15 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $12 | $15 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $8 | $13 | $19 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $19 | $22 | $27 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $19 | $23 | $27 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $18 | $27 | $40 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $17 | $20 | $25 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $13 | $18 | $24 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $63 | $97 | $136 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $63 | $93 | $123 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $63 | $97 | $136 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $24 | $60 | $94 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $16 | $29 | $43 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $31 | $44 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $24 | $26 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $20 | $25 | $27 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $36 | $57 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $20 | $26 | $34 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $7 | $18 | $28 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $8 | $11 |
| Immunization admin injection single CPT 90471 • Preventive Care | $7 | $17 | $25 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $5 | $10 | $18 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $314 | $355 | $378 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $267 | $307 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $101 | $113 | $120 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $22 | $24 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $109 | $119 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $47 | $51 | $56 |
| Varicella vaccine CPT 90716 • Preventive Care | $187 | $210 | $222 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $120 | $138 | $159 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $220 | $229 | $248 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $64 | $91 | $132 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $89 | $108 | $139 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $73 | $102 | $144 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $100 | $129 | $162 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $100 | $128 | $158 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $89 | $131 | $182 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $131 | $154 | $198 |