| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $37 | $37 | $37 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $23 | $23 | $23 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $9 | $9 | $9 |
| Immunization admin injection single CPT 90471 • Preventive Care | $4 | $12 | $21 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $7 | $11 | $15 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $371 | $383 | $395 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $272 | $282 | $292 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $19 | $67 | $115 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $24 | $24 | $25 |
| MMR vaccine CPT 90707 • Preventive Care | $35 | $72 | $109 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $56 | $57 | $58 |
| Varicella vaccine CPT 90716 • Preventive Care | $52 | $134 | $217 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $20 | $76 | $132 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $244 | $251 | $259 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $60 | $85 | $109 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $66 | $72 | $77 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $70 | $76 | $82 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $74 | $103 | $132 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $100 | $114 | $129 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $117 | $133 | $148 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $121 | $127 | $133 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $48 | $57 | $66 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $53 | $79 | $104 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $60 | $82 | $104 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $61 | $71 | $82 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $84 | $100 | $116 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $98 | $111 | $124 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $111 | $122 | $133 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $4 | $15 | $27 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $18 | $102 | $186 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $181 | $227 | $272 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $30 | $185 | $340 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $166 | $166 | $166 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $165 | $165 | $165 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $130 | $130 | $130 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $31 | $251 | $472 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $22 | $273 | $522 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $130 | $261 | $503 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $131 | $259 | $495 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $39 | $275 | $615 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $215 | $215 | $215 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $90 | $90 | $90 |
| Spirometry CPT 94010 • Pulmonology | $15 | $27 | $46 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $10 | $31 | $56 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $11 | $70 | $162 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $24 | $32 | $39 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $27 | $90 | $154 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $2 | $12 | $27 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $6 | $15 | $21 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $12 | $12 | $12 |