| Physical therapy evaluation low complexity CPT 97161 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy evaluation moderate complexity CPT 97162 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $51 | $51 | $51 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $34 | $34 | $34 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $30 | $30 | $30 |
| Wheelchair management training each 15 minutes CPT 97542 • Physical Therapy | $29 | $29 | $29 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $30 | $30 | $30 |
| Orthotic management and training each 15 min CPT 97760 • Physical Therapy | $43 | $43 | $43 |
| Prosthetic training each 15 minutes CPT 97761 • Physical Therapy | $37 | $37 | $37 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $12 | $12 | $12 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $11 | $11 | $11 |
| Immunization admin injection single CPT 90471 • Preventive Care | $12 | $12 | $12 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $11 | $11 | $11 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $279 | $279 | $279 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $219 | $219 | $219 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $87 | $87 | $87 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| MMR vaccine CPT 90707 • Preventive Care | $82 | $82 | $82 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $42 | $42 | $42 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $163 | $163 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $100 | $100 | $100 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $183 | $183 | $183 |
| Genetic counseling 30 minutes CPT 96040 • Preventive Care | $40 | $40 | $40 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $67 | $67 | $67 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $101 | $101 | $101 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $76 | $76 | $76 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $90 | $90 | $90 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $115 | $115 | $115 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $133 | $133 | $133 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $113 | $113 | $113 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $62 | $62 | $62 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $92 | $92 | $92 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $67 | $67 | $67 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $101 | $101 | $101 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $104 | $104 | $104 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $85 | $85 | $85 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $119 | $119 | $119 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $25 | $25 | $25 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $320 | $415 | $559 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $400 | $453 | $559 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $365 | $441 | $559 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $143 | $143 | $143 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $147 | $147 | $147 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $100 | $100 | $100 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $365 | $802 | $1,642 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $400 | $814 | $1,642 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $365 | $802 | $1,642 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $400 | $814 | $1,642 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $400 | $814 | $1,642 |