| Facet joint injection lumbar first level CPT 64493 • Pain Management | $226 | $394 | $450 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $99 | $362 | $450 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $99 | $362 | $450 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $450 | $582 | $978 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $99 | $362 | $450 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $99 | $362 | $450 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $35 | $56 | $66 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $103 | $103 | $103 |
| Special stain group II CPT 88313 • Pathology | $11 | $53 | $74 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $26 | $63 | $81 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $93 | $93 | $93 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $226 | $394 | $450 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $108 | $352 | $625 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $108 | $294 | $625 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $420 | $574 | $625 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $420 | $530 | $625 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $420 | $530 | $625 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $420 | $574 | $625 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $420 | $486 | $625 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $450 | $670 | $978 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $450 | $796 | $1,832 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $309 | $415 | $450 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $450 | $796 | $1,832 |
| Complex uroflowmetry CPT 51741 • Urology | $99 | $99 | $99 |
| Post-void residual urine measurement CPT 51798 • Urology | $99 | $99 | $99 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $226 | $394 | $450 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $625 | $713 | $978 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $450 | $582 | $978 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $420 | $486 | $625 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $625 | $713 | $978 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $450 | $734 | $1,584 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $450 | $734 | $1,584 |
| Laser vaporization of prostate CPT 52648 • Urology | $450 | $734 | $1,584 |
| Circumcision CPT 54150 • Urology | $450 | $582 | $978 |
| Orchiectomy simple CPT 54520 • Urology | $450 | $635 | $1,189 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $450 | $635 | $1,189 |
| Vasectomy CPT 55250 • Urology | $450 | $670 | $978 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $309 | $415 | $450 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $450 | $1,364 | $4,106 |