| Electrical stimulation unattended CPT 97014 • Physical Therapy | $9 | $9 | $9 |
| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $8 | $8 | $8 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $10 | $10 | $10 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $10 | $10 | $10 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $21 | $21 | $21 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $24 | $24 | $24 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $21 | $21 | $21 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $20 | $20 | $20 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $13 | $13 | $13 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $74 | $74 | $74 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $74 | $74 | $74 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $74 | $74 | $74 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $27 | $27 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $24 | $24 | $24 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $23 | $23 | $23 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $25 | $25 | $25 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $36 | $36 | $36 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $31 | $31 | $31 |
| 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 | $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 | $103 | $103 | $104 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $108 | $108 | $108 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $112 | $112 | $112 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $126 | $126 | $126 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $122 | $122 | $122 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $107 | $107 | $107 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $153 | $153 | $153 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $69 | $69 | $69 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $107 | $107 | $107 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $117 | $117 | $117 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $127 | $127 | $127 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $23 | $23 | $23 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $114 | $114 | $114 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $208 | $208 | $208 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $55 | $55 | $55 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $99 | $99 | $99 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $98 | $98 | $98 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $77 | $77 | $77 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $269 | $269 | $269 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $297 | $297 | $297 |