| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $66 | $79 | $92 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $81 | $92 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $66 | $79 | $92 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $45 | $55 | $63 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $23 | $33 | $42 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $29 | $37 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $21 | $28 | $36 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $30 | $37 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $31 | $42 | $52 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $27 | $35 | $45 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $23 | $44 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $14 | $18 | $22 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $21 | $38 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $13 | $16 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $329 | $345 | $362 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $238 | $251 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $102 | $113 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $22 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $93 | $99 | $106 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $50 | $52 | $55 |
| Varicella vaccine CPT 90716 • Preventive Care | $82 | $162 | $211 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $86 | $129 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $28 | $160 | $237 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $91 | $91 | $91 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $106 | $153 | $179 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $111 | $142 | $191 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $116 | $192 | $276 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $131 | $211 | $302 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $200 | $251 | $302 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $148 | $235 | $324 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $256 | $290 | $324 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $138 | $183 | $228 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $51 | $135 | $243 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $102 | $145 | $179 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $112 | $140 | $182 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $208 | $240 | $271 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $123 | $184 | $290 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $50 | $170 | $303 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $19 | $51 | $67 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $184 | $274 | $406 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $18 | $277 | $446 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $693 | $735 | $776 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $163 | $240 | $379 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $163 | $290 | $388 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $127 | $201 | $262 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $30 | $388 | $569 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $261 | $447 | $632 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $189 | $452 | $592 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $30 | $238 | $379 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $35 | $267 | $427 |