| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $495 | $731 | $1,354 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $495 | $682 | $1,354 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $495 | $822 | $2,056 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $495 | $822 | $2,056 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $495 | $898 | $2,056 |
| Carpal tunnel release CPT 64721 • Orthopedics | $498 | $630 | $1,079 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $50 | $344 | $520 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $249 | $426 | $520 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $249 | $403 | $520 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $249 | $426 | $520 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $495 | $825 | $2,056 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $249 | $426 | $520 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $50 | $344 | $520 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $249 | $403 | $520 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $109 | $398 | $520 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $249 | $388 | $520 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $109 | $386 | $520 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $50 | $332 | $520 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $495 | $627 | $1,079 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $109 | $398 | $520 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $109 | $338 | $460 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $249 | $426 | $520 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $249 | $427 | $525 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $249 | $448 | $525 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $323 | $460 | $525 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $400 | $487 | $525 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $400 | $494 | $525 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $400 | $495 | $525 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $400 | $495 | $525 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $323 | $595 | $1,079 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $323 | $855 | $2,056 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $323 | $426 | $520 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $495 | $822 | $2,056 |
| Complex uroflowmetry CPT 51741 • Urology | $50 | $80 | $109 |
| Post-void residual urine measurement CPT 51798 • Urology | $50 | $80 | $109 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $249 | $388 | $520 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $498 | $657 | $1,079 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $495 | $654 | $1,079 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $400 | $486 | $525 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $498 | $629 | $1,079 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $495 | $895 | $1,798 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $495 | $895 | $1,798 |
| Laser vaporization of prostate CPT 52648 • Urology | $495 | $771 | $1,798 |
| Circumcision CPT 54150 • Urology | $323 | $592 | $1,079 |
| Orchiectomy simple CPT 54520 • Urology | $495 | $722 | $1,354 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $495 | $784 | $1,354 |
| Vasectomy CPT 55250 • Urology | $498 | $628 | $1,079 |
| Prostate biopsy needle or punch CPT 55700 • Urology | $400 | $400 | $400 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $323 | $445 | $520 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $323 | $1,282 | $4,528 |