| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $333 | $333 | $333 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $21 | $53 | $86 |
| Special stain group II CPT 88313 • Pathology | $5 | $43 | $62 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $28 | $52 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $42 | $42 | $42 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $13 | $49 | $68 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $57 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $19 | $48 | $93 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $10 | $11 | $12 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $15 | $15 | $15 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $11 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $11 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $22 | $24 | $25 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $22 | $26 | $29 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $25 | $25 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $19 | $21 | $23 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $15 | $18 | $25 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $74 | $81 | $84 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $75 | $81 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $81 | $84 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $51 | $55 | $58 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $29 | $31 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $26 | $27 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $27 | $27 | $27 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $45 | $45 | $45 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $40 | $45 | $56 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $22 | $22 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $13 | $18 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $11 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $209 | $252 | $274 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $88 | $91 | $92 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $10 | $10 | $10 |
| MMR vaccine CPT 90707 • Preventive Care | $72 | $83 | $93 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $38 | $38 | $40 |
| Varicella vaccine CPT 90716 • Preventive Care | $124 | $124 | $124 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $151 | $151 | $151 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $99 | $140 | $160 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $123 | $153 | $168 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $108 | $153 | $175 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $131 | $175 | $197 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $118 | $167 | $191 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $136 | $194 | $222 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $148 | $210 | $241 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $89 | $126 | $144 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $95 | $134 | $154 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $95 | $134 | $153 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $112 | $150 | $169 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $107 | $150 | $172 |