| Influenza virus assay with direct optical CPT 87804 • Laboratory | $11 | $11 | $11 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $8 | $10 | $11 |
| Family psychotherapy with patient CPT 90847 • Mental Health | $77 | $77 | $77 |
| Brief emotional/behavioral assessment CPT 96127 • Mental Health | $5 | $5 | $5 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $30 | $30 | $30 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $30 | $30 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $30 | $94 | $126 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $30 | $30 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $42 | $48 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $30 | $30 |
| Subsequent hospital care moderate complexity CPT 99232 • Office Visits | $46 | $46 | $46 |
| Subsequent hospital care high complexity CPT 99233 • Office Visits | $67 | $67 | $67 |
| Cataract surgery with intraocular lens insertion CPT 66984 • Ophthalmology | $452 | $452 | $452 |
| Intravitreal injection therapeutic agent CPT 67028 • Ophthalmology | $130 | $130 | $130 |
| Cytopathology concentration technique CPT 88108 • Pathology | $22 | $33 | $55 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $55 | $55 | $55 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $18 | $21 | $25 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $11 | $11 | $11 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $27 | $27 | $27 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $23 | $23 | $23 |
| Cytogenetics molecular interpretation CPT 88291 • Pathology | $19 | $23 | $26 |
| Surgical pathology gross and micro exam level II CPT 88302 • Pathology | $28 | $28 | $28 |
| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $37 | $37 | $37 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $81 | $81 | $81 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $189 | $189 | $189 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $230 | $258 | $287 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $60 | $60 | $60 |
| Special stain group II CPT 88313 • Pathology | $38 | $41 | $42 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $21 | $44 | $59 |
| Frozen section pathology each additional CPT 88332 • Pathology | $24 | $24 | $24 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $42 | $50 | $55 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $53 | $61 | $65 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $42 | $60 | $74 |
| Microdissection manual CPT 88381 • Pathology | $92 | $92 | $92 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $11 | $11 | $11 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $20 | $20 | $20 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $18 | $18 | $18 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $60 | $60 | $60 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $21 | $21 | $21 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $21 | $21 |
| MMR vaccine CPT 90707 • Preventive Care | $100 | $101 | $103 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $40 | $40 | $40 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $63 | $63 | $63 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $77 | $77 | $77 |