| Immunization admin injection each additional CPT 90472 • Preventive Care | $30 | $30 | $30 |
| HPV vaccine 9-valent CPT 90651 • Preventive Care | $79 | $79 | $79 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $271 | $342 | $413 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $147 | $147 | $147 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $4 | $4 | $4 |
| MMR vaccine CPT 90707 • Preventive Care | $18 | $18 | $18 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $6 | $6 | $6 |
| Varicella vaccine CPT 90716 • Preventive Care | $46 | $46 | $46 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $140 | $177 | $214 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $282 | $290 | $299 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $118 | $118 | $118 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $65 | $65 | $65 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $15 | $15 | $15 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $11 | $106 | $201 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $39 | $39 | $39 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $125 | $125 | $125 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $331 | $331 | $331 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $6 | $30 | $55 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $87 | $125 | $164 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $30 | $59 | $87 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $48 | $48 | $48 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $10 | $93 | $176 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $196 | $196 | $196 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $211 | $211 | $211 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $18 | $18 | $18 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $4 | $4 | $4 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $35 | $162 | $288 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $186 | $364 | $541 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $109 | $109 | $110 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $261 | $301 | $340 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $204 | $235 | $267 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $282 | $282 | $282 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $21 | $21 | $21 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $29 | $29 | $29 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $44 | $44 | $44 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $95 | $95 | $95 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $48 | $48 | $48 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $89 | $89 | $89 |
| Spirometry CPT 94010 • Pulmonology | $14 | $14 | $14 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $16 | $16 | $16 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $44 | $44 | $44 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $36 | $43 | $50 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $48 | $48 | $48 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $6 | $27 | $48 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $26 | $26 | $26 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $44 | $44 | $44 |
| Gas dilution lung volumes CPT 94727 • Pulmonology | $45 | $45 | $45 |
| Diffusing capacity (DLCO) CPT 94729 • Pulmonology | $113 | $113 | $113 |
| Pulse oximetry single measurement CPT 94760 • Pulmonology | $0 | $0 | $0 |
| Pulse oximetry continuous overnight CPT 94762 • Pulmonology | $6 | $28 | $50 |