| Varicella vaccine CPT 90716 • Preventive Care | $80 | $80 | $80 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $80 | $80 | $80 |
| Zoster vaccine recombinant adjuvanted CPT 90750 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient infant CPT 99381 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 1-4 CPT 99382 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 5-11 CPT 99383 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $80 | $80 | $80 |
| Preventive visit new patient age 65+ CPT 99387 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $80 | $80 | $80 |
| Preventive visit established patient age 65+ CPT 99397 • Preventive Care | $80 | $80 | $80 |
| Cervical or vaginal cancer screening pelvic exam HCPCS G0101 • Preventive Care | $80 | $80 | $80 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $80 | $80 | $80 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $80 | $80 | $80 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $80 | $80 | $80 |
| Initial preventive physical exam (Welcome to Medicare) HCPCS G0402 • Preventive Care | $80 | $80 | $80 |
| Annual wellness visit initial HCPCS G0438 • Preventive Care | $80 | $80 | $80 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $80 | $80 | $80 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $80 | $80 | $80 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $80 | $80 | $80 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $80 | $80 | $80 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $80 | $80 | $80 |
| Ventilation assist and management initiation CPT 94002 • Pulmonology | $80 | $80 | $80 |
| Spirometry CPT 94010 • Pulmonology | $80 | $80 | $80 |
| Spirometry before and after bronchodilator CPT 94060 • Pulmonology | $80 | $80 | $80 |
| Bronchospasm provocation evaluation CPT 94070 • Pulmonology | $80 | $80 | $80 |
| Respiratory flow volume loop CPT 94375 • Pulmonology | $80 | $80 | $80 |
| Cardiopulmonary exercise test CPT 94621 • Pulmonology | $80 | $80 | $80 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $80 | $80 | $80 |
| Aerosol or vapor inhalation initial demonstration CPT 94664 • Pulmonology | $80 | $80 | $80 |
| Plethysmography lung volumes CPT 94726 • Pulmonology | $80 | $80 | $80 |
| Gas dilution lung volumes CPT 94727 • Pulmonology | $80 | $80 | $80 |
| Diffusing capacity (DLCO) CPT 94729 • Pulmonology | $80 | $80 | $80 |
| Pulse oximetry single measurement CPT 94760 • Pulmonology | $80 | $80 | $80 |
| Pulse oximetry continuous overnight CPT 94762 • Pulmonology | $80 | $80 | $80 |
| Radiation therapy planning simple CPT 77261 • Radiation Therapy | $80 | $80 | $80 |
| Radiation therapy planning intermediate CPT 77262 • Radiation Therapy | $80 | $80 | $80 |
| Radiation therapy planning complex CPT 77263 • Radiation Therapy | $80 | $80 | $80 |
| Radiation therapy simulation simple CPT 77280 • Radiation Therapy | $80 | $80 | $80 |
| Radiation therapy simulation complex CPT 77290 • Radiation Therapy | $80 | $80 | $80 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $80 | $80 | $80 |
| Radiation therapy dose calculation CPT 77300 • Radiation Therapy | $80 | $80 | $80 |
| IMRT radiation therapy plan CPT 77301 • Radiation Therapy | $80 | $80 | $80 |
| Radiation treatment device design complex CPT 77334 • Radiation Therapy | $80 | $80 | $80 |