| Immunization admin injection each additional CPT 90472 • Preventive Care | $0 | $2 | $4 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $336 | $336 | $336 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $230 | $230 | $231 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $10 | $57 | $104 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $20 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $10 | $55 | $100 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $39 | $39 | $39 |
| Varicella vaccine CPT 90716 • Preventive Care | $20 | $107 | $195 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $13 | $13 | $13 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $219 | $229 | $239 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $34 | $68 | $102 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $11 | $59 | $106 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $17 | $64 | $111 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $63 | $63 | $63 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $9 | $65 | $121 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $53 | $97 | $140 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $23 | $87 | $152 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $9 | $51 | $92 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $34 | $52 | $69 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $10 | $39 | $69 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $11 | $59 | $107 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $81 | $81 | $81 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $88 | $102 | $116 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $92 | $109 | $126 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $12 | $24 | $36 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $17 | $17 | $17 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $168 | $241 | $315 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $84 | $199 | $315 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $155 | $155 | $156 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $155 | $155 | $155 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $121 | $122 | $122 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $92 | $160 | $229 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $39 | $147 | $256 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $13 | $13 | $13 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $73 | $198 | $324 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $25 | $25 | $25 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $205 | $688 | $1,171 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $85 | $85 | $85 |
| Spirometry CPT 94010 • Pulmonology | $5 | $15 | $24 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $18 | $26 | $35 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $33 | $45 | $57 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $7 | $21 | $35 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $72 | $107 | $142 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $4 | $4 | $4 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $15 | $16 | $16 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $11 | $31 | $50 |
| Gas dilution lung volumes CPT 94727 • Pulmonology | $11 | $26 | $42 |
| Diffusing capacity (DLCO) CPT 94729 • Pulmonology | $8 | $17 | $26 |
| Pulse oximetry single measurement CPT 94760 • Pulmonology | $1 | $1 | $2 |
| Pulse oximetry continuous overnight CPT 94762 • Pulmonology | $11 | $17 | $22 |