| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $61 | $61 | $61 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $41 | $41 | $41 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $22 | $41 | $59 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $41 | $59 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $20 | $36 | $52 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $39 | $56 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $24 | $44 | $64 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $21 | $39 | $56 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $13 | $20 | $26 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $10 | $16 | $22 |
| Immunization admin injection single CPT 90471 • Preventive Care | $17 | $23 | $26 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $9 | $17 | $22 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $395 | $415 | $436 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $272 | $287 | $303 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $123 | $123 | $123 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $24 | $28 | $32 |
| MMR vaccine CPT 90707 • Preventive Care | $117 | $117 | $117 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $55 | $57 | $59 |
| Varicella vaccine CPT 90716 • Preventive Care | $230 | $230 | $230 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $141 | $164 | $208 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $282 | $293 | $311 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $71 | $71 | $71 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $74 | $122 | $170 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $81 | $129 | $177 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $80 | $151 | $187 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $63 | $158 | $212 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $87 | $145 | $203 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $102 | $171 | $238 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $112 | $184 | $255 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $42 | $71 | $101 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $69 | $94 | $120 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $49 | $123 | $165 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $76 | $141 | $180 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $76 | $129 | $183 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $83 | $159 | $198 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $93 | $137 | $199 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $29 | $29 | $29 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $46 | $46 | $46 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $285 | $285 | $285 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $285 | $285 | $285 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $76 | $129 | $183 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $140 | $222 | $263 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $94 | $168 | $206 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $243 | $359 | $437 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $266 | $379 | $492 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $120 | $261 | $453 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $267 | $448 | $629 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $303 | $312 | $321 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $202 | $1,552 | $2,333 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $75 | $118 | $161 |