| Surgical pathology gross and micro exam level III CPT 88304 • Pathology | $0 | $36 | $69 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $0 | $48 | $116 |
| Surgical pathology gross and micro exam level V CPT 88307 • Pathology | $1 | $183 | $469 |
| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $4 | $514 | $1,616 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $0 | $70 | $182 |
| Special stain group II CPT 88313 • Pathology | $1 | $105 | $289 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $1 | $137 | $382 |
| Frozen section pathology each additional CPT 88332 • Pathology | $0 | $73 | $211 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $1 | $56 | $140 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $1 | $64 | $162 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $0 | $173 | $482 |
| Microdissection manual CPT 88381 • Pathology | $2 | $66 | $131 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $0 | $7 | $17 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $6 | $18 | $39 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $17 | $34 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $20 | $41 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $7 | $18 | $39 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $17 | $40 | $84 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $18 | $45 | $97 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $15 | $39 | $83 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $16 | $37 | $77 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $9 | $24 | $50 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $66 | $124 | $234 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $124 | $234 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $66 | $124 | $234 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $37 | $43 | $48 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $17 | $49 | $108 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $18 | $44 | $93 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $16 | $42 | $91 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $17 | $45 | $95 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $20 | $62 | $135 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $17 | $53 | $115 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $16 | $38 | $75 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $6 | $27 | $67 |
| Immunization admin injection single CPT 90471 • Preventive Care | $15 | $36 | $75 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $31 | $67 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $314 | $339 | $369 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $443 | $842 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $101 | $107 | $115 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $38 | $72 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $101 | $107 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $50 | $77 | $125 |
| Varicella vaccine CPT 90716 • Preventive Care | $187 | $199 | $215 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $120 | $230 | $439 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $220 | $256 | $308 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $84 | $170 | $318 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $5 | $150 | $333 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $64 | $165 | $347 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $103 | $209 | $393 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $5 | $160 | $381 |