| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $66 | $95 | $124 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $124 | $124 | $124 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $40 | $55 | $70 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $22 | $34 | $45 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $21 | $31 | $40 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $19 | $26 | $39 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $34 | $46 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $31 | $45 | $59 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $27 | $38 | $50 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $11 | $16 | $21 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $10 | $12 |
| Immunization admin injection single CPT 90471 • Preventive Care | $24 | $37 | $60 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $10 | $14 | $17 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $329 | $329 | $329 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $241 | $250 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $102 | $103 | $104 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $21 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $97 | $98 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $36 | $43 | $50 |
| Varicella vaccine CPT 90716 • Preventive Care | $192 | $193 | $195 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $117 | $117 | $117 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $216 | $217 | $219 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $48 | $48 | $48 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $86 | $105 | $123 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $112 | $144 | $177 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $116 | $150 | $184 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $99 | $225 | $369 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $127 | $164 | $201 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $182 | $182 | $182 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $159 | $173 | $188 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $96 | $105 | $113 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $95 | $129 | $162 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $72 | $96 | $121 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $82 | $129 | $177 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $87 | $134 | $181 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $122 | $157 | $193 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $208 | $296 | $369 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $34 | $46 | $58 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $224 | $224 | $224 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $232 | $296 | $411 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $256 | $372 | $487 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $151 | $194 | $255 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $150 | $171 | $192 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $150 | $219 | $287 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $30 | $301 | $715 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $30 | $94 | $159 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $161 | $245 | $329 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $30 | $109 | $188 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $212 | $348 | $484 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $273 | $890 | $1,508 |