| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $130 | $130 | $130 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $90 | $90 | $90 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $102 | $102 | $102 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $169 | $169 | $169 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $185 | $185 | $185 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $74 | $74 | $74 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $79 | $79 | $79 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $85 | $85 | $85 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $94 | $94 | $94 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $130 | $130 | $130 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $145 | $145 | $145 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $109 | $109 | $109 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $7,500 | $7,500 | $7,500 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $5,000 | $5,000 | $5,000 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $166 | $2,583 | $5,000 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $155 | $155 | $155 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $129 | $129 | $129 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $5,000 | $5,000 | $5,000 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $5,000 | $5,000 | $5,000 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $7,500 | $7,500 | $7,500 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $5,000 | $5,000 | $5,000 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $5,000 | $5,000 | $5,000 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $5,000 | $5,000 | $5,000 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $9 | $9 | $9 |
| Radiation therapy planning complex CPT 77263 • Radiation Therapy | $134 | $134 | $134 |
| Radiation therapy simulation simple CPT 77280 • Radiation Therapy | $30 | $30 | $30 |
| Radiation therapy simulation complex CPT 77290 • Radiation Therapy | $66 | $66 | $66 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $180 | $180 | $180 |
| Radiation therapy dose calculation CPT 77300 • Radiation Therapy | $26 | $26 | $26 |
| IMRT radiation therapy plan CPT 77301 • Radiation Therapy | $336 | $336 | $336 |
| Radiation treatment device design complex CPT 77334 • Radiation Therapy | $48 | $48 | $48 |
| Radiation treatment management 5 treatments CPT 77427 • Radiation Therapy | $155 | $155 | $155 |
| Radiation therapy management complete course CPT 77431 • Radiation Therapy | $84 | $84 | $84 |
| Polysomnography age 6 or older CPT 95810 • Sleep Medicine | $588 | $588 | $588 |
| Polysomnography with CPAP titration CPT 95811 • Sleep Medicine | $620 | $620 | $620 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $467 | $467 | $467 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $88 | $146 | $203 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $1,754 | $7,877 | $14,000 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $1,459 | $4,480 | $7,500 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $675 | $4,132 | $7,589 |
| Complex uroflowmetry CPT 51741 • Urology | $14 | $14 | $14 |
| Post-void residual urine measurement CPT 51798 • Urology | $12 | $12 | $12 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $245 | $3,872 | $7,500 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $267 | $2,633 | $5,000 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $7,500 | $7,500 | $7,500 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $228 | $2,614 | $5,000 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $183 | $3,841 | $7,500 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $424 | $4,962 | $9,500 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $859 | $5,180 | $9,500 |
| Laser vaporization of prostate CPT 52648 • Urology | $11,250 | $11,250 | $11,250 |