| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $8 | $8 | $8 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $8 | $8 | $8 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $17 | $17 | $17 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $20 | $20 | $20 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $17 | $17 | $17 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $16 | $16 | $16 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $10 | $10 | $10 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $59 | $59 | $59 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $40 | $40 | $40 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $22 | $22 | $22 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $19 | $19 | $19 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $19 | $19 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $19 | $19 | $19 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $28 | $28 | $28 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $24 | $24 | $24 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $17 | $17 | $17 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $2 | $2 | $2 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $10 | $10 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $335 | $335 | $335 |
| 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 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $82 | $82 | $82 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $86 | $86 | $86 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $89 | $89 | $89 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $101 | $101 | $101 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $97 | $97 | $97 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $113 | $113 | $113 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $122 | $122 | $122 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $52 | $52 | $52 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $79 | $79 | $79 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $65 | $65 | $65 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $88 | $88 | $88 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $94 | $94 | $94 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $101 | $101 | $101 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $37 | $37 | $37 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $88 | $210 | $331 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $88 | $88 | $88 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $162 | $162 | $162 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $161 | $161 | $161 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $127 | $127 | $127 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $228 | $228 | $229 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $256 | $256 | $256 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $125 | $125 | $125 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $329 | $329 | $329 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $1,149 | $1,149 | $1,149 |