| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $433 | $536 | $600 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $446 | $513 | $600 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $446 | $549 | $600 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $800 | $2,538 | $5,916 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $53 | $330 | $600 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $24 | $312 | $600 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $490 | $562 | $600 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $255 | $435 | $600 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $490 | $562 | $600 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $171 | $457 | $600 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $73 | $338 | $600 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $600 | $744 | $1,076 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $490 | $573 | $600 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $297 | $449 | $600 |
| Rotavirus vaccine pentavalent CPT 90680 • Preventive Care | $111 | $111 | $111 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $125 | $374 | $600 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $450 | $633 | $800 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $547 | $679 | $800 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $450 | $732 | $922 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $689 | $803 | $922 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $689 | $803 | $922 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $689 | $803 | $922 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $689 | $1,041 | $1,874 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $800 | $1,322 | $1,874 |
| Radiation therapy simulation simple CPT 77280 • Radiation Therapy | $62 | $72 | $83 |
| Radiation therapy simulation complex CPT 77290 • Radiation Therapy | $152 | $190 | $229 |
| 3-dimensional radiation therapy plan CPT 77295 • Radiation Therapy | $198 | $244 | $290 |
| Radiation therapy dose calculation CPT 77300 • Radiation Therapy | $27 | $33 | $38 |
| IMRT radiation therapy plan CPT 77301 • Radiation Therapy | $550 | $550 | $550 |
| Radiation treatment device design complex CPT 77334 • Radiation Therapy | $63 | $69 | $74 |
| Radiation physics consultation CPT 77336 • Radiation Therapy | $34 | $58 | $83 |
| Radiation treatment delivery superficial CPT 77407 • Radiation Therapy | $58 | $111 | $164 |
| Radiation treatment delivery 3 or more MeV CPT 77412 • Radiation Therapy | $97 | $131 | $164 |
| Proton beam treatment simple CPT 77520 • Radiation Therapy | $361 | $522 | $682 |
| Proton beam treatment complex CPT 77523 • Radiation Therapy | $796 | $844 | $893 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $450 | $450 | $450 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $450 | $450 | $450 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $450 | $1,563 | $3,426 |
| Complex uroflowmetry CPT 51741 • Urology | $15 | $15 | $15 |
| Post-void residual urine measurement CPT 51798 • Urology | $23 | $23 | $23 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $368 | $503 | $600 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $800 | $1,314 | $1,926 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $450 | $1,139 | $1,926 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $450 | $879 | $1,149 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $800 | $1,314 | $1,926 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $450 | $1,568 | $2,934 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $450 | $1,568 | $2,934 |
| Laser vaporization of prostate CPT 52648 • Urology | $450 | $1,711 | $3,010 |
| Circumcision CPT 54150 • Urology | $450 | $929 | $1,549 |
| Orchiectomy simple CPT 54520 • Urology | $450 | $1,094 | $1,926 |