| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $15 | $43 | $93 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $21 | $69 | $153 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $80 | $238 | $624 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $120 | $365 | $927 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $11 | $83 | $244 |
| Special stain group II CPT 88313 • Pathology | $5 | $61 | $180 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $13 | $77 | $214 |
| Frozen section pathology each additional CPT 88332 • Pathology | $6 | $37 | $117 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $24 | $84 | $209 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $30 | $96 | $244 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $55 | $110 | $257 |
| Microdissection manual CPT 88381 • Pathology | $30 | $59 | $74 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $0 | $4 | $6 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $6 | $12 | $18 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $9 | $14 | $17 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $9 | $14 | $20 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $6 | $16 | $30 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $17 | $25 | $35 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $16 | $26 | $37 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $15 | $22 | $31 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $16 | $34 | $59 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $9 | $15 | $22 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $49 | $182 | $500 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $49 | $75 | $105 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $49 | $75 | $105 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $33 | $56 | $95 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $27 | $37 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $19 | $27 | $38 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $16 | $25 | $35 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $16 | $26 | $38 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $19 | $27 | $35 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $17 | $25 | $32 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $30 | $50 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $10 | $14 |
| Immunization admin injection single CPT 90471 • Preventive Care | $20 | $28 | $45 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $12 | $18 | $32 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $314 | $395 | $557 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $310 | $490 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $101 | $106 | $118 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $25 | $33 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $117 | $166 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $50 | $58 | $76 |
| Varicella vaccine CPT 90716 • Preventive Care | $187 | $231 | $325 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $117 | $156 | $254 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $216 | $262 | $365 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $68 | $119 | $172 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $79 | $120 | $179 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $77 | $116 | $137 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $100 | $165 | $285 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $125 | $170 | $277 |