| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $15 | $28 | $39 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $13 | $23 | $31 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $18 | $32 | $51 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $24 | $41 | $71 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $18 | $33 | $52 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $45 | $71 | $107 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $107 | $239 | $429 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $113 | $329 | $654 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $24 | $86 | $142 |
| Special stain group II CPT 88313 • Pathology | $12 | $39 | $102 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $16 | $79 | $131 |
| Frozen section pathology each additional CPT 88332 • Pathology | $23 | $50 | $83 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $26 | $75 | $112 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $73 | $128 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $30 | $92 | $153 |
| Microdissection manual CPT 88381 • Pathology | $38 | $116 | $263 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $4 | $20 | $77 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $29 | $77 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $11 | $29 | $77 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $31 | $77 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $30 | $77 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $46 | $77 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $22 | $50 | $82 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $22 | $46 | $77 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $21 | $44 | $77 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $16 | $35 | $77 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $58 | $112 | $241 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $58 | $112 | $241 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $67 | $116 | $241 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $28 | $90 | $165 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $18 | $45 | $89 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $50 | $79 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $16 | $36 | $76 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $24 | $29 | $40 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $37 | $57 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $23 | $32 | $49 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $7 | $24 | $40 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $17 | $31 |
| Immunization admin injection single CPT 90471 • Preventive Care | $7 | $22 | $40 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $5 | $16 | $31 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $144 | $296 | $378 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $355 | $648 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $112 | $135 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $29 | $54 |
| MMR vaccine CPT 90707 • Preventive Care | $80 | $97 | $109 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $50 | $62 | $96 |
| Varicella vaccine CPT 90716 • Preventive Care | $120 | $188 | $221 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $120 | $184 | $335 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $158 | $217 | $248 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $75 | $147 | $249 |