| Stereotactic radiosurgery (SRS) cranial CPT 77371 • Radiation Therapy | $80 | $80 | $80 |
| Stereotactic body radiation therapy (SBRT) CPT 77373 • Radiation Therapy | $80 | $80 | $80 |
| Radiation treatment delivery superficial CPT 77407 • Radiation Therapy | $80 | $80 | $80 |
| Radiation treatment delivery 3 or more MeV CPT 77412 • Radiation Therapy | $80 | $80 | $80 |
| Radiation treatment management 5 treatments CPT 77427 • Radiation Therapy | $80 | $80 | $80 |
| Radiation therapy management complete course CPT 77431 • Radiation Therapy | $80 | $80 | $80 |
| Proton beam treatment simple CPT 77520 • Radiation Therapy | $80 | $80 | $80 |
| Proton beam treatment complex CPT 77523 • Radiation Therapy | $80 | $80 | $80 |
| Polysomnography under age 6 CPT 95782 • Sleep Medicine | $80 | $80 | $80 |
| Polysomnography under age 6 with CPAP CPT 95783 • Sleep Medicine | $80 | $80 | $80 |
| Sleep study unattended CPT 95800 • Sleep Medicine | $80 | $80 | $80 |
| Sleep study unattended minimum 3 channels CPT 95801 • Sleep Medicine | $80 | $80 | $80 |
| Multiple sleep latency test (MSLT) CPT 95805 • Sleep Medicine | $80 | $80 | $80 |
| Polysomnography age 6 or older CPT 95810 • Sleep Medicine | $80 | $80 | $80 |
| Polysomnography with CPAP titration CPT 95811 • Sleep Medicine | $80 | $80 | $80 |
| CPAP combination oral/nasal mask HCPCS A7027 • Sleep Medicine | $80 | $80 | $80 |
| Respiratory assist device BiPAP without backup HCPCS E0470 • Sleep Medicine | $80 | $80 | $80 |
| CPAP device continuous positive airway pressure HCPCS E0601 • Sleep Medicine | $80 | $80 | $80 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $80 | $80 | $80 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $80 | $80 | $80 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $80 | $80 | $80 |
| Complex uroflowmetry CPT 51741 • Urology | $80 | $80 | $80 |
| Post-void residual urine measurement CPT 51798 • Urology | $80 | $80 | $80 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $80 | $80 | $80 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $80 | $80 | $80 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $80 | $80 | $80 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $80 | $80 | $80 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $80 | $80 | $80 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $80 | $80 | $80 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $80 | $80 | $80 |
| Laser vaporization of prostate CPT 52648 • Urology | $80 | $80 | $80 |
| Circumcision CPT 54150 • Urology | $80 | $80 | $80 |
| Orchiectomy simple CPT 54520 • Urology | $80 | $80 | $80 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $80 | $80 | $80 |
| Vasectomy CPT 55250 • Urology | $80 | $80 | $80 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $80 | $80 | $80 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $80 | $80 | $80 |