| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $550 | $550 | $550 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $142 | $142 | $142 |
| Special stain group II CPT 88313 • Pathology | $102 | $102 | $102 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $80 | $80 | $80 |
| Frozen section pathology each additional CPT 88332 • Pathology | $69 | $69 | $69 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $112 | $112 | $112 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $128 | $128 | $128 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $54 | $54 | $54 |
| Microdissection manual CPT 88381 • Pathology | $263 | $263 | $263 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $14 | $14 | $14 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $30 | $30 | $30 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $28 | $28 | $28 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $35 | $35 | $35 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $34 | $34 | $34 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $71 | $71 | $71 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $82 | $82 | $82 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $71 | $71 | $71 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $65 | $65 | $65 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $42 | $42 | $42 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $241 | $241 | $241 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $241 | $241 | $241 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $241 | $241 | $241 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $165 | $165 | $165 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $89 | $89 | $89 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $79 | $79 | $79 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $76 | $76 | $76 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $40 | $40 | $40 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $31 | $31 | $31 |
| Immunization admin injection single CPT 90471 • Preventive Care | $40 | $40 | $40 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $31 | $31 | $31 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $648 | $648 | $648 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $54 | $54 | $54 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $96 | $96 | $96 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $335 | $335 | $335 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $249 | $249 | $249 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $260 | $260 | $260 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $105 | $187 | $270 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $105 | $168 | $232 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $105 | $201 | $298 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $119 | $232 | $345 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $373 | $373 | $373 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $158 | $158 | $158 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $172 | $172 | $172 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $172 | $172 | $172 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $261 | $261 | $261 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $201 | $201 | $201 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $287 | $287 | $287 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $232 | $232 | $232 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $59 | $59 | $59 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $84 | $84 | $84 |