| Group therapeutic procedures CPT 97150 • Physical Therapy | $10 | $10 | $10 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $48 | $48 | $48 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $66 | $66 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $48 | $48 | $48 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $33 | $33 | $33 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $26 | $26 | $26 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $17 | $17 | $17 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $16 | $16 | $16 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $24 | $24 | $24 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $19 | $19 | $19 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $17 | $17 | $17 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $22 | $23 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $11 | $11 | $11 |
| 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 | $230 | $230 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $104 | $104 | $104 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $20 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $100 | $100 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $39 | $39 | $39 |
| Varicella vaccine CPT 90716 • Preventive Care | $195 | $195 | $195 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $133 | $133 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $75 | $75 | $75 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $82 | $82 | $82 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $82 | $121 | $159 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $89 | $135 | $180 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $89 | $132 | $174 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $203 | $203 | $203 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $114 | $114 | $114 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $70 | $70 | $70 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $77 | $77 | $77 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $77 | $77 | $77 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $85 | $85 | $85 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $73 | $85 | $96 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $28 | $28 | $28 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $102 | $102 | $102 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $303 | $303 | $303 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $110 | $110 | $110 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $137 | $137 | $137 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $90 | $90 | $90 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $246 | $246 | $247 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $264 | $264 | $264 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $123 | $123 | $123 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $268 | $268 | $268 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $761 | $761 | $761 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $76 | $76 | $76 |
| Spirometry CPT 94010 • Pulmonology | $40 | $40 | $40 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $46 | $46 | $46 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $46 | $46 | $46 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $127 | $127 | $127 |