| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $18 | $45 | $76 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $18 | $65 | $96 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $169 | $297 | $507 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $131 | $419 | $1,076 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $53 | $72 | $102 |
| Special stain group II CPT 88313 • Pathology | $7 | $32 | $65 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $58 | $111 | $253 |
| Frozen section pathology each additional CPT 88332 • Pathology | $18 | $39 | $76 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $23 | $80 | $212 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $29 | $89 | $246 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $66 | $120 | $291 |
| Microdissection manual CPT 88381 • Pathology | $52 | $97 | $159 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $8 | $13 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $17 | $28 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $12 | $20 | $34 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $21 | $34 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $11 | $19 | $30 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $41 | $62 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $24 | $46 | $71 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $22 | $39 | $62 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $21 | $39 | $57 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $14 | $25 | $38 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $74 | $132 | $213 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $74 | $132 | $213 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $79 | $133 | $213 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $97 | $147 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $49 | $78 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $27 | $46 | $69 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $25 | $40 | $67 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $25 | $42 | $71 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $57 | $102 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $23 | $50 | $88 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $7 | $30 | $53 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $15 | $30 |
| Immunization admin injection single CPT 90471 • Preventive Care | $7 | $29 | $53 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $5 | $17 | $30 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $290 | $337 | $378 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $284 | $364 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $98 | $110 | $118 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $23 | $27 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $105 | $114 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $49 | $53 | $56 |
| Varicella vaccine CPT 90716 • Preventive Care | $173 | $205 | $230 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $117 | $139 | $188 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $187 | $223 | $248 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $57 | $133 | $236 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $60 | $126 | $172 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $63 | $113 | $183 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $74 | $156 | $289 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $71 | $161 | $281 |