| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $70 | $77 | $84 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $70 | $75 | $78 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $47 | $52 | $58 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $24 | $28 | $34 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $22 | $27 | $34 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $23 | $27 | $30 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $26 | $32 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $21 | $31 | $37 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $21 | $29 | $35 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $19 | $24 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $7 | $10 | $12 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $18 | $27 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $13 | $21 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $150 | $279 | $369 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $197 | $268 | $362 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $84 | $98 | $115 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $5 | $18 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $47 | $86 | $107 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $38 | $44 | $55 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $180 | $215 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $110 | $133 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $187 | $204 | $241 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $44 | $44 | $44 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $101 | $124 | $181 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $78 | $114 | $190 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $78 | $128 | $198 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $5 | $129 | $224 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $5 | $103 | $129 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $5 | $136 | $251 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $160 | $160 | $160 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $5 | $71 | $96 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $75 | $92 | $102 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $68 | $106 | $174 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $83 | $119 | $191 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $86 | $101 | $115 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $5 | $109 | $208 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $5 | $72 | $133 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $32 | $44 | $63 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $56 | $120 | $184 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $90 | $230 | $364 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $191 | $213 | $235 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $161 | $217 | $272 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $130 | $192 | $281 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $112 | $141 | $190 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $30 | $117 | $177 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $146 | $276 | $406 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $66 | $183 | $303 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $30 | $207 | $382 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $30 | $261 | $474 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $234 | $602 | $1,278 |