| Immunization admin first vaccine component CPT 90460 • Preventive Care | $10 | $10 | $10 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $5 | $5 | $5 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $2 | $6 | $10 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $27 | $27 | $27 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $257 | $257 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $18 | $55 | $92 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $21 | $21 | $22 |
| MMR vaccine CPT 90707 • Preventive Care | $14 | $54 | $93 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $6 | $21 | $37 |
| Varicella vaccine CPT 90716 • Preventive Care | $82 | $122 | $163 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $67 | $67 | $67 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $187 | $187 | $187 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $16 | $61 | $106 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $11 | $61 | $111 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $58 | $95 | $115 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $66 | $96 | $127 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $13 | $88 | $127 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $15 | $101 | $147 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $24 | $91 | $159 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $10 | $10 | $10 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $37 | $37 | $37 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $74 | $74 | $74 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $42 | $76 | $111 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $86 | $86 | $86 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $61 | $92 | $122 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $20 | $20 | $20 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $5 | $22 | $38 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $5 | $94 | $183 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $18 | $18 | $18 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $68 | $118 | $169 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $163 | $163 | $163 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $163 | $163 | $163 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $127 | $127 | $127 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $30 | $106 | $182 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $20 | $25 | $30 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $131 | $160 | $189 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $30 | $32 | $35 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $74 | $74 | $74 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $1,278 | $1,278 | $1,278 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $91 | $91 | $91 |
| Spirometry CPT 94010 • Pulmonology | $18 | $24 | $30 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $10 | $24 | $37 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $32 | $46 | $59 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $30 | $33 | $36 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $30 | $90 | $150 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $30 | $30 | $30 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $30 | $30 | $30 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $52 | $52 | $52 |
| Gas dilution lung volumes CPT 94727 • Pulmonology | $30 | $36 | $42 |