| Immunization admin first vaccine component CPT 90460 • Preventive Care | $20 | $20 | $20 |
| Immunization admin each additional component CPT 90461 • Preventive Care | $10 | $10 | $10 |
| 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 | $168 | $168 | $168 |
| Pneumococcal conjugate vaccine 13-valent CPT 90670 • Preventive Care | $258 | $258 | $258 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $92 | $92 | $92 |
| Influenza vaccine quadrivalent preservative free CPT 90686 • Preventive Care | $20 | $20 | $20 |
| MMR vaccine CPT 90707 • Preventive Care | $9 | $9 | $9 |
| Tdap vaccine age 7 years or older CPT 90715 • Preventive Care | $4 | $22 | $40 |
| Varicella vaccine CPT 90716 • Preventive Care | $163 | $163 | $163 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $27 | $27 | $27 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $94 | $94 | $94 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $74 | $74 | $74 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $12 | $12 | $12 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $7 | $60 | $113 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $8 | $67 | $127 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $39 | $94 | $123 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $22 | $82 | $142 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $62 | $62 | $62 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $6 | $6 | $6 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $102 | $102 | $102 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $7 | $7 | $7 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $42 | $42 | $42 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $114 | $114 | $114 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $50 | $50 | $50 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $8 | $8 | $8 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $4 | $4 | $4 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $45 | $45 | $45 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $338 | $338 | $338 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $169 | $169 | $169 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $163 | $163 | $163 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $130 | $130 | $130 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $88 | $88 | $88 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $36 | $36 | $36 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $89 | $89 | $89 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $18 | $18 | $18 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $28 | $28 | $28 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $31 | $31 | $31 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $198 | $198 | $198 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $91 | $91 | $91 |
| Spirometry CPT 94010 • Pulmonology | $26 | $26 | $26 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $27 | $27 | $27 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $28 | $28 | $28 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $19 | $19 | $19 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $72 | $72 | $72 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $7 | $7 | $7 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $16 | $16 | $16 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $52 | $52 | $52 |
| Gas dilution lung volumes CPT 94727 • Pulmonology | $34 | $34 | $34 |