| Preventive visit new patient age 12-17 CPT 99384 • Preventive Care | $112 | $112 | $112 |
| Preventive visit new patient age 18-39 CPT 99385 • Preventive Care | $108 | $108 | $108 |
| Preventive visit new patient age 40-64 CPT 99386 • Preventive Care | $125 | $125 | $125 |
| Preventive visit established patient infant CPT 99391 • Preventive Care | $82 | $82 | $82 |
| Preventive visit established patient age 1-4 CPT 99392 • Preventive Care | $87 | $87 | $87 |
| Preventive visit established patient age 5-11 CPT 99393 • Preventive Care | $87 | $87 | $87 |
| Preventive visit established patient age 12-17 CPT 99394 • Preventive Care | $95 | $95 | $95 |
| Preventive visit established patient age 18-39 CPT 99395 • Preventive Care | $97 | $97 | $97 |
| Preventive visit established patient age 40-64 CPT 99396 • Preventive Care | $104 | $104 | $104 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $850 | $850 | $850 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $436 | $568 | $700 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $436 | $568 | $700 |
| Annual wellness visit subsequent HCPCS G0439 • Preventive Care | $108 | $108 | $108 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $635 | $635 | $635 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $549 | $625 | $700 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $700 | $700 | $700 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $549 | $625 | $700 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $549 | $625 | $700 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $850 | $850 | $850 |
| Nebulizer inhalation treatment CPT 94640 • Pulmonology | $9 | $9 | $9 |
| Radiation therapy simulation complex CPT 77290 • Radiation Therapy | $152 | $152 | $152 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $198 | $198 | $198 |
| Radiation physics consultation CPT 77336 • Radiation Therapy | $34 | $34 | $34 |
| Radiation treatment delivery superficial CPT 77407 • Radiation Therapy | $58 | $58 | $58 |
| Radiation treatment delivery 3 or more MeV CPT 77412 • Radiation Therapy | $97 | $97 | $97 |
| Proton beam treatment simple CPT 77520 • Radiation Therapy | $682 | $682 | $682 |
| Proton beam treatment complex CPT 77523 • Radiation Therapy | $893 | $893 | $893 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $850 | $850 | $850 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $850 | $850 | $850 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $1,500 | $1,500 | $1,500 |
| Complex uroflowmetry CPT 51741 • Urology | $50 | $50 | $50 |
| Post-void residual urine measurement CPT 51798 • Urology | $18 | $34 | $50 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $355 | $495 | $635 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $700 | $1,040 | $1,379 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $850 | $850 | $850 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $700 | $808 | $916 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $700 | $700 | $700 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $1,050 | $1,050 | $1,050 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $1,050 | $1,497 | $1,945 |
| Laser vaporization of prostate CPT 52648 • Urology | $1,500 | $1,500 | $1,500 |
| Circumcision CPT 54150 • Urology | $635 | $935 | $1,235 |
| Orchiectomy simple CPT 54520 • Urology | $850 | $850 | $850 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $1,050 | $1,050 | $1,050 |
| Vasectomy CPT 55250 • Urology | $700 | $968 | $1,235 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $850 | $850 | $850 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $850 | $850 | $850 |