| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $29 | $29 | $29 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $259 | $259 | $259 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $70 | $70 | $70 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $126 | $126 | $126 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $126 | $126 | $126 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $99 | $99 | $99 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $45 | $160 | $275 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $45 | $45 | $45 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $45 | $45 | $45 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $45 | $45 | $45 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $1,360 | $1,360 | $1,360 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $93 | $93 | $93 |
| Spirometry CPT 94010 • Pulmonology | $45 | $45 | $45 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $45 | $45 | $45 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $45 | $45 | $45 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $37 | $37 | $37 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $45 | $45 | $45 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $15 | $15 | $15 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $39 | $45 | $52 |
| Gas dilution lung volumes CPT 94727 • Pulmonology | $8 | $8 | $8 |
| Pulse oximetry single measurement CPT 94760 • Pulmonology | $2 | $2 | $2 |
| Pulse oximetry continuous overnight CPT 94762 • Pulmonology | $25 | $25 | $25 |
| Radiation therapy planning simple CPT 77261 • Radiation Therapy | $61 | $61 | $61 |
| Radiation therapy planning complex CPT 77263 • Radiation Therapy | $146 | $146 | $146 |
| Radiation therapy simulation simple CPT 77280 • Radiation Therapy | $46 | $122 | $198 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $209 | $209 | $209 |
| IMRT radiation therapy plan CPT 77301 • Radiation Therapy | $1,560 | $1,560 | $1,560 |
| Radiation physics consultation CPT 77336 • Radiation Therapy | $13 | $39 | $65 |
| Stereotactic radiosurgery (SRS) cranial CPT 77371 • Radiation Therapy | $945 | $945 | $945 |
| Stereotactic body radiation therapy (SBRT) CPT 77373 • Radiation Therapy | $926 | $926 | $926 |
| Radiation treatment delivery 3 or more MeV CPT 77412 • Radiation Therapy | $45 | $45 | $45 |
| Radiation therapy management complete course CPT 77431 • Radiation Therapy | $92 | $92 | $92 |
| Proton beam treatment simple CPT 77520 • Radiation Therapy | $706 | $706 | $707 |
| Polysomnography under age 6 CPT 95782 • Sleep Medicine | $876 | $876 | $876 |
| Polysomnography under age 6 with CPAP CPT 95783 • Sleep Medicine | $791 | $791 | $791 |
| Sleep study unattended CPT 95800 • Sleep Medicine | $42 | $42 | $42 |
| Sleep study unattended minimum 3 channels CPT 95801 • Sleep Medicine | $45 | $45 | $45 |
| Multiple sleep latency test (MSLT) CPT 95805 • Sleep Medicine | $79 | $79 | $79 |
| Polysomnography age 6 or older CPT 95810 • Sleep Medicine | $585 | $585 | $585 |
| Polysomnography with CPAP titration CPT 95811 • Sleep Medicine | $611 | $611 | $611 |
| CPAP combination oral/nasal mask HCPCS A7027 • Sleep Medicine | $108 | $108 | $108 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $78 | $78 | $78 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $319 | $319 | $320 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $45 | $45 | $45 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $45 | $45 | $45 |
| Post-void residual urine measurement CPT 51798 • Urology | $11 | $11 | $11 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $45 | $45 | $45 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $45 | $45 | $45 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $45 | $45 | $45 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $45 | $45 | $45 |