| Physical therapy evaluation high complexity CPT 97163 • Physical Therapy | $75 | $75 | $75 |
| Physical therapy re-evaluation CPT 97164 • Physical Therapy | $52 | $52 | $52 |
| Therapeutic activities each 15 minutes CPT 97530 • Physical Therapy | $27 | $27 | $27 |
| Self-care/home management training each 15 min CPT 97535 • Physical Therapy | $25 | $25 | $25 |
| Physical performance test each 15 minutes CPT 97750 • Physical Therapy | $22 | $22 | $22 |
| Immunization admin first vaccine component CPT 90460 • Preventive Care | $22 | $22 | $22 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $8 | $8 | $8 |
| Immunization admin injection single CPT 90471 • Preventive Care | $18 | $18 | $18 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $13 | $13 | $13 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $316 | $316 | $316 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $99 | $99 | $99 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $19 | $19 | $19 |
| MMR vaccine CPT 90707 • Preventive Care | $94 | $94 | $94 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $34 | $34 | $34 |
| Varicella vaccine CPT 90716 • Preventive Care | $184 | $184 | $184 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $176 | $176 | $176 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $101 | $101 | $101 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $96 | $96 | $96 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $118 | $118 | $118 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $124 | $124 | $124 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $103 | $103 | $103 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $149 | $149 | $149 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $83 | $83 | $83 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $104 | $104 | $104 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $88 | $88 | $88 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $114 | $114 | $114 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $99 | $99 | $99 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $105 | $105 | $105 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $116 | $116 | $116 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $235 | $235 | $235 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $235 | $235 | $235 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $130 | $130 | $130 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $103 | $103 | $103 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $139 | $139 | $139 |
| Spirometry CPT 94010 • Pulmonology | $7 | $7 | $7 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $32 | $32 | $32 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $6 | $6 | $6 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $17 | $17 | $17 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $46 | $46 | $46 |
| Diffusing capacity (DLCO) CPT 94729 • Pulmonology | $46 | $46 | $46 |
| Pulse oximetry continuous overnight CPT 94762 • Pulmonology | $20 | $20 | $20 |
| Sleep study unattended CPT 95800 • Sleep Medicine | $124 | $124 | $124 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $82 | $82 | $82 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $31 | $31 | $31 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $504 | $504 | $504 |
| Complex uroflowmetry CPT 51741 • Urology | $6 | $6 | $6 |
| Post-void residual urine measurement CPT 51798 • Urology | $11 | $11 | $11 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $193 | $193 | $193 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $126 | $126 | $126 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $639 | $639 | $639 |