| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $10 | $27 | $60 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $36 | $68 | $103 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $90 | $255 | $412 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $160 | $295 | $391 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $11 | $59 | $85 |
| Special stain group II CPT 88313 • Pathology | $5 | $62 | $115 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $27 | $65 | $90 |
| Frozen section pathology each additional CPT 88332 • Pathology | $13 | $26 | $42 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $26 | $75 | $134 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $16 | $66 | $151 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $20 | $102 | $178 |
| Microdissection manual CPT 88381 • Pathology | $19 | $79 | $153 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $0 | $3 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $6 | $8 | $10 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $10 | $12 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $14 | $22 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $6 | $13 | $21 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $16 | $27 | $44 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $18 | $31 | $51 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $14 | $27 | $44 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $16 | $26 | $41 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $9 | $12 | $14 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $65 | $96 | $148 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $65 | $96 | $148 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $71 | $99 | $148 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $44 | $66 | $101 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $33 | $57 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $18 | $32 | $49 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $15 | $29 | $48 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $16 | $21 | $25 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $20 | $43 | $72 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $17 | $37 | $61 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $20 | $22 | $25 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $7 | $11 | $19 |
| Immunization admin injection single CPT 90471 • Preventive Care | $18 | $21 | $25 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $12 | $15 | $19 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $314 | $328 | $336 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $289 | $364 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $101 | $108 | $118 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $24 | $31 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $104 | $114 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $49 | $51 | $54 |
| Varicella vaccine CPT 90716 • Preventive Care | $187 | $204 | $230 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $119 | $143 | $190 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $219 | $220 | $220 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $59 | $96 | $162 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $63 | $115 | $170 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $67 | $116 | $176 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $79 | $122 | $198 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $76 | $118 | $193 |