| Frozen section pathology first specimen CPT 88331 • Pathology | $13 | $46 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $22 | $22 | $22 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $12 | $40 | $68 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $30 | $54 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $20 | $57 | $93 |
| Microdissection manual CPT 88381 • Pathology | $65 | $65 | $65 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $3 | $7 | $10 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $5 | $8 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $5 | $9 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $3 | $8 | $12 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $9 | $9 | $9 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $9 | $9 | $9 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $8 | $16 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $8 | $8 | $8 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $5 | $5 | $5 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $37 | $37 | $37 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $37 | $60 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $37 | $37 | $37 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $25 | $41 | $58 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $9 | $9 | $9 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $10 | $10 | $10 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $8 | $17 | $27 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $9 | $9 | $9 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $10 | $10 | $10 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $9 | $22 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $10 | $10 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $92 | $92 |
| MMR vaccine CPT 90707 • Preventive Care | $93 | $93 | $93 |
| Varicella vaccine CPT 90716 • Preventive Care | $16 | $16 | $16 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $13 | $13 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $37 | $37 | $37 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $38 | $72 | $106 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $58 | $85 | $111 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $60 | $88 | $116 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $68 | $100 | $131 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $49 | $49 | $49 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $77 | $112 | $148 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $64 | $64 | $64 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $35 | $35 | $35 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $53 | $78 | $102 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $38 | $70 | $102 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $43 | $77 | $112 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $44 | $44 | $44 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $48 | $86 | $123 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $69 | $100 | $132 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $38 | $38 | $38 |