| Proton beam treatment complex CPT 77523 • Radiation Therapy | $968 | $968 | $968 |
| Polysomnography under age 6 CPT 95782 • Sleep Medicine | $384 | $575 | $767 |
| Polysomnography under age 6 with CPAP CPT 95783 • Sleep Medicine | $699 | $836 | $972 |
| Sleep study unattended CPT 95800 • Sleep Medicine | $34 | $34 | $34 |
| Sleep study unattended minimum 3 channels CPT 95801 • Sleep Medicine | $40 | $57 | $75 |
| Multiple sleep latency test (MSLT) CPT 95805 • Sleep Medicine | $68 | $236 | $404 |
| Polysomnography age 6 or older CPT 95810 • Sleep Medicine | $395 | $490 | $585 |
| CPAP combination oral/nasal mask HCPCS A7027 • Sleep Medicine | $80 | $117 | $154 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $1,219 | $1,219 | $1,219 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $359 | $429 | $499 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $30 | $30 | $30 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $1,441 | $1,441 | $1,441 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $30 | $30 | $30 |
| Complex uroflowmetry CPT 51741 • Urology | $5 | $18 | $30 |
| Post-void residual urine measurement CPT 51798 • Urology | $12 | $12 | $12 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $78 | $78 | $78 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $263 | $263 | $263 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $309 | $309 | $309 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $30 | $30 | $30 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $30 | $30 | $30 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $420 | $420 | $420 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $789 | $789 | $789 |
| Laser vaporization of prostate CPT 52648 • Urology | $101 | $101 | $101 |
| Circumcision CPT 54150 • Urology | $30 | $30 | $30 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $540 | $540 | $540 |
| Vasectomy CPT 55250 • Urology | $111 | $111 | $111 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $30 | $30 | $30 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $30 | $643 | $1,255 |