| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $11 | $29 | $39 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $24 | $45 | $81 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $23 | $49 | $66 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $21 | $40 | $57 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $31 | $57 | $88 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $34 | $56 | $109 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $48 | $74 | $142 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $96 | $216 | $294 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $132 | $266 | $355 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $44 | $80 | $129 |
| Special stain group II CPT 88313 • Pathology | $45 | $79 | $111 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $21 | $54 | $86 |
| Frozen section pathology each additional CPT 88332 • Pathology | $7 | $27 | $45 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $33 | $80 | $114 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $42 | $86 | $113 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $48 | $101 | $135 |
| Microdissection manual CPT 88381 • Pathology | $101 | $158 | $205 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $6 | $8 | $10 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $19 | $21 | $24 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $20 | $26 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $24 | $25 | $26 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $17 | $22 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $42 | $45 | $50 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $44 | $48 | $57 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $41 | $45 | $49 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $39 | $42 | $45 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $29 | $29 | $30 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $111 | $131 | $150 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $137 | $143 | $150 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $83 | $110 | $137 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $75 | $94 | $128 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $52 | $56 | $65 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $48 | $51 | $55 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $26 | $41 | $54 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $27 | $42 | $57 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $50 | $62 | $77 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $34 | $50 | $66 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $27 | $30 | $34 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $13 | $17 | $21 |
| Immunization admin injection single CPT 90471 • Preventive Care | $27 | $43 | $70 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $17 | $20 | $21 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $369 | $374 | $378 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $241 | $251 | $260 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $105 | $118 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $41 | $62 |
| MMR vaccine CPT 90707 • Preventive Care | $109 | $110 | $110 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $56 | $94 | $133 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $192 | $221 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $126 | $130 | $135 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $187 | $217 | $248 |