| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $19 | $23 | $27 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $21 | $30 | $40 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $18 | $29 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $15 | $24 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $9 | $12 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $14 | $19 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $10 | $10 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $395 | $395 | $395 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $257 | $262 | $272 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $102 | $123 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $22 | $24 |
| MMR vaccine CPT 90707 • Preventive Care | $19 | $76 | $117 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $37 | $48 | $59 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $185 | $230 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $96 | $141 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $28 | $166 | $282 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $48 | $48 | $48 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $59 | $91 | $106 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $64 | $95 | $111 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $63 | $98 | $116 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $69 | $100 | $131 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $48 | $88 | $127 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $59 | $103 | $148 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $64 | $111 | $159 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $32 | $63 | $95 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $37 | $37 | $37 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $53 | $77 | $102 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $58 | $85 | $112 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $58 | $58 | $58 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $48 | $97 | $123 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $66 | $69 | $71 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $6 | $22 | $38 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $85 | $150 | $184 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $68 | $159 | $251 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $136 | $237 | $338 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $66 | $131 | $163 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $120 | $141 | $151 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $79 | $108 | $127 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $205 | $230 | $243 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $223 | $248 | $273 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $25 | $124 | $252 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $222 | $306 | $349 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $129 | $189 | $265 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $649 | $1,068 | $1,278 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $56 | $74 | $91 |
| Spirometry CPT 94010 • Pulmonology | $17 | $23 | $26 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $31 | $35 | $37 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $42 | $50 | $59 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $9 | $27 | $37 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $30 | $95 | $150 |