| Surgical pathology gross and micro exam level VI CPT 88309 • Pathology | $509 | $509 | $509 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $132 | $132 | $132 |
| Special stain group II CPT 88313 • Pathology | $31 | $63 | $95 |
| Frozen section pathology first specimen CPT 88331 • Pathology | $48 | $64 | $79 |
| Frozen section pathology each additional CPT 88332 • Pathology | $63 | $63 | $63 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $68 | $85 | $103 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $77 | $77 | $77 |
| Morphometric analysis tumor quantitative CPT 88360 • Pathology | $32 | $62 | $93 |
| Microdissection manual CPT 88381 • Pathology | $246 | $246 | $246 |
| Hot or cold packs application CPT 97010 • Physical Therapy | $5 | $5 | $5 |
| Electrical stimulation unattended CPT 97014 • Physical Therapy | $6 | $8 | $10 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $9 | $10 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $11 | $12 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $12 | $12 | $13 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $20 | $20 | $20 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $23 | $23 | $23 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $24 | $24 | $25 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $22 | $22 | $22 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $12 | $12 | $12 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $66 | $66 | $66 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $83 | $83 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $83 | $83 | $83 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $56 | $56 | $56 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $30 | $30 | $30 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $30 | $30 | $30 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $27 | $28 | $29 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $31 | $31 | $31 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $40 | $40 | $40 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $35 | $36 | $38 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $5 | $5 |
| 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 | $230 | $244 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $98 | $104 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $20 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $19 | $59 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $39 | $39 | $39 |
| Varicella vaccine CPT 90716 • Preventive Care | $24 | $110 | $195 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $73 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $94 | $94 | $94 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $83 | $83 | $83 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $87 | $99 | $111 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $90 | $103 | $116 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $71 | $85 | $98 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $119 | $119 | $119 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $89 | $118 | $148 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $125 | $125 | $125 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $51 | $62 | $73 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $102 | $102 | $102 |