| Vasopneumatic device therapy CPT 97016 • Physical Therapy | $7 | $7 | $7 |
| Electrical stimulation attended each 15 minutes CPT 97032 • Physical Therapy | $8 | $13 | $18 |
| Ultrasound therapy each 15 minutes CPT 97035 • Physical Therapy | $8 | $13 | $18 |
| Therapeutic exercises each 15 minutes CPT 97110 • Physical Therapy | $15 | $26 | $37 |
| Neuromuscular reeducation each 15 minutes CPT 97112 • Physical Therapy | $16 | $32 | $47 |
| Gait training each 15 minutes CPT 97116 • Physical Therapy | $17 | $27 | $37 |
| Manual therapy one or more regions each 15 min CPT 97140 • Physical Therapy | $14 | $24 | $34 |
| Group therapeutic procedures CPT 97150 • Physical Therapy | $10 | $10 | $10 |
| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $41 | $79 | $117 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $59 | $87 | $115 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $117 | $117 | $117 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $41 | $54 | $80 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $16 | $35 | $54 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $19 | $33 | $47 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $19 | $19 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $19 | $33 | $48 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $28 | $28 | $28 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $24 | $24 | $24 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $13 | $19 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $11 | $17 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $15 | $19 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $14 | $17 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $430 | $430 | $430 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $230 | $230 | $230 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $104 | $107 | $110 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $20 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $100 | $103 | $105 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $39 | $49 | $59 |
| Varicella vaccine CPT 90716 • Preventive Care | $195 | $200 | $205 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $221 | $221 | $221 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $105 | $119 | $148 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $110 | $132 | $155 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $114 | $139 | $164 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $97 | $138 | $186 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $126 | $152 | $177 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $113 | $161 | $209 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $157 | $190 | $223 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $136 | $136 | $136 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $145 | $145 | $145 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $142 | $142 | $142 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $159 | $159 | $159 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $160 | $160 | $160 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $121 | $146 | $170 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $130 | $184 | $238 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $30 | $30 | $30 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $27 | $139 | $252 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $137 | $197 | $258 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $105 | $118 | $131 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $131 | $131 | $131 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $103 | $128 | $153 |