| Radiation treatment delivery 3 or more MeV CPT 77412 • Radiation Therapy | $30 | $30 | $30 |
| Radiation treatment management 5 treatments CPT 77427 • Radiation Therapy | $186 | $186 | $186 |
| Radiation therapy management complete course CPT 77431 • Radiation Therapy | $104 | $104 | $104 |
| Proton beam treatment simple CPT 77520 • Radiation Therapy | $166 | $499 | $831 |
| Proton beam treatment complex CPT 77523 • Radiation Therapy | $968 | $968 | $968 |
| Polysomnography under age 6 CPT 95782 • Sleep Medicine | $384 | $523 | $662 |
| Polysomnography under age 6 with CPAP CPT 95783 • Sleep Medicine | $699 | $756 | $813 |
| Sleep study unattended CPT 95800 • Sleep Medicine | $34 | $34 | $34 |
| Sleep study unattended minimum 3 channels CPT 95801 • Sleep Medicine | $34 | $37 | $40 |
| Multiple sleep latency test (MSLT) CPT 95805 • Sleep Medicine | $291 | $315 | $339 |
| Polysomnography age 6 or older CPT 95810 • Sleep Medicine | $495 | $495 | $495 |
| Polysomnography with CPAP titration CPT 95811 • Sleep Medicine | $103 | $103 | $103 |
| CPAP combination oral/nasal mask HCPCS A7027 • Sleep Medicine | $153 | $153 | $154 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $121 | $121 | $121 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $50 | $274 | $498 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $30 | $30 | $30 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $30 | $30 | $30 |
| Complex uroflowmetry CPT 51741 • Urology | $8 | $8 | $8 |
| Post-void residual urine measurement CPT 51798 • Urology | $9 | $9 | $9 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $238 | $238 | $238 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $30 | $30 | $30 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $299 | $299 | $299 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $30 | $30 | $30 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $30 | $30 | $30 |
| Laser vaporization of prostate CPT 52648 • Urology | $135 | $135 | $135 |
| Circumcision CPT 54150 • Urology | $30 | $30 | $30 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $30 | $30 | $30 |
| Vasectomy CPT 55250 • Urology | $111 | $111 | $111 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $30 | $30 | $30 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $30 | $30 | $30 |