| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $19 | $26 | $44 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $17 | $51 | $83 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $129 | $235 | $467 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $65 | $222 | $442 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $20 | $45 | $59 |
| Special stain group II CPT 88313 • Pathology | $5 | $13 | $26 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $28 | $75 | $130 |
| Frozen section pathology each additional CPT 88332 • Pathology | $25 | $37 | $51 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $21 | $58 | $89 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $28 | $49 | $93 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $56 | $85 | $122 |
| Microdissection manual CPT 88381 • Pathology | $55 | $83 | $117 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $0 | $4 | $8 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $12 | $14 | $20 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $16 | $24 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $3 | $16 | $24 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $9 | $13 | $16 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $31 | $41 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $25 | $33 | $43 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $23 | $29 | $36 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $29 | $38 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $17 | $19 | $22 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $75 | $99 | $144 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $75 | $99 | $144 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $99 | $144 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $51 | $67 | $98 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $33 | $44 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $33 | $45 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $26 | $33 | $39 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $27 | $35 | $42 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $36 | $48 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $23 | $33 | $42 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $7 | $21 | $39 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $9 | $15 |
| Immunization admin injection single CPT 90471 • Preventive Care | $7 | $20 | $35 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $5 | $13 | $25 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $268 | $367 | $545 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $257 | $307 | $404 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $138 | $175 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $26 | $37 |
| MMR vaccine CPT 90707 • Preventive Care | $91 | $116 | $169 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $53 | $86 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $223 | $324 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $152 | $209 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $176 | $248 | $382 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $78 | $136 | $219 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $89 | $146 | $190 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $89 | $147 | $238 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $100 | $151 | $202 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $100 | $157 | $262 |