| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $83 | $135 | $187 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $83 | $156 | $240 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $83 | $161 | $240 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $57 | $107 | $166 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $20 | $55 | $87 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $44 | $66 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $52 | $76 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $20 | $44 | $64 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $23 | $49 | $67 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $20 | $61 | $99 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $35 | $55 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $15 | $28 |
| Immunization admin injection single CPT 90471 • Preventive Care | $17 | $26 | $31 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $12 | $19 | $22 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $274 | $328 | $395 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $232 | $410 | $645 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $100 | $123 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $21 | $24 |
| MMR vaccine CPT 90707 • Preventive Care | $93 | $99 | $117 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $50 | $75 | $96 |
| Varicella vaccine CPT 90716 • Preventive Care | $16 | $152 | $230 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $120 | $220 | $334 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $37 | $190 | $282 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $78 | $78 | $78 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $126 | $164 | $225 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $132 | $172 | $243 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $137 | $177 | $238 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $156 | $197 | $259 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $151 | $194 | $259 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $115 | $196 | $304 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $189 | $223 | $244 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $79 | $133 | $171 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $10 | $117 | $192 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $121 | $152 | $190 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $132 | $167 | $210 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $100 | $161 | $212 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $110 | $164 | $182 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $66 | $149 | $259 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $0 | $39 | $81 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $66 | $174 | $262 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $36 | $336 | $524 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $215 | $453 | $813 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $163 | $199 | $294 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $136 | $259 | $390 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $92 | $192 | $261 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $391 | $439 | $581 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $96 | $399 | $660 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $161 | $359 | $598 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $30 | $388 | $728 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $159 | $445 | $777 |