| Total shoulder replacement CPT 23472 • Orthopedics | $450 | $450 | $450 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $450 | $450 | $450 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $450 | $450 | $450 |
| Closed treatment distal radial fracture CPT 25600 • Orthopedics | $450 | $450 | $450 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $625 | $625 | $625 |
| Total hip replacement CPT 27130 • Orthopedics | $450 | $450 | $450 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $450 | $450 | $450 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $450 | $450 | $450 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $450 | $450 | $450 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $450 | $450 | $450 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $450 | $450 | $450 |
| Total knee replacement CPT 27447 • Orthopedics | $450 | $450 | $450 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $450 | $450 | $450 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $450 | $450 | $450 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $450 | $450 | $450 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $450 | $450 | $450 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $450 | $450 | $450 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $450 | $450 | $450 |
| Carpal tunnel release CPT 64721 • Orthopedics | $625 | $625 | $625 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $450 | $450 | $450 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $450 | $450 | $450 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $450 | $450 | $450 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $450 | $450 | $450 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $625 | $625 | $625 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $450 | $450 | $450 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $450 | $450 | $450 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $450 | $450 | $450 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $450 | $450 | $450 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $450 | $450 | $450 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $450 | $450 | $450 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $450 | $450 | $450 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $450 | $450 | $450 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $450 | $450 | $450 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $450 | $450 | $450 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $29 | $29 | $29 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $450 | $450 | $450 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $338 | $338 | $338 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $625 | $625 | $625 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $625 | $625 | $625 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $625 | $625 | $625 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $625 | $625 | $625 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $625 | $625 | $625 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $625 | $625 | $625 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $625 | $625 | $625 |
| Stereotactic radiosurgery (SRS) cranial CPT 77371 • Radiation Therapy | $1,178 | $1,178 | $1,178 |