| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $96 | $461 | $644 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $369 | $575 | $644 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $96 | $507 | $644 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $96 | $461 | $644 |
| Surgical pathology gross and micro exam level IV CPT 88305 • Pathology | $51 | $80 | $108 |
| Special stain group I for microorganisms CPT 88312 • Pathology | $170 | $170 | $170 |
| Special stain group II CPT 88313 • Pathology | $122 | $122 | $122 |
| Immunohistochemistry each antibody CPT 88341 • Pathology | $43 | $43 | $43 |
| Immunohistochemistry first antibody CPT 88342 • Pathology | $153 | $153 | $153 |
| Immunization admin injection single CPT 90471 • Preventive Care | $25 | $25 | $25 |
| Immunization admin injection each additional CPT 90472 • Preventive Care | $19 | $19 | $19 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $279 | $522 | $644 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $279 | $398 | $644 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $279 | $522 | $644 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $449 | $634 | $798 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $449 | $579 | $644 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $449 | $630 | $798 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $449 | $579 | $644 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $449 | $579 | $644 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $369 | $552 | $644 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $604 | $631 | $644 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $298 | $529 | $644 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $604 | $631 | $644 |
| Complex uroflowmetry CPT 51741 • Urology | $96 | $96 | $96 |
| Post-void residual urine measurement CPT 51798 • Urology | $96 | $96 | $96 |
| Cystourethroscopy diagnostic CPT 52000 • Urology | $279 | $522 | $644 |
| Cystourethroscopy with tumor fulguration small CPT 52234 • Urology | $369 | $552 | $644 |
| Cystourethroscopy with tumor fulguration medium CPT 52235 • Urology | $369 | $552 | $644 |
| Cystourethroscopy with dilation of ureteral stricture CPT 52260 • Urology | $449 | $579 | $644 |
| Cystourethroscopy with ureteral stent insertion CPT 52332 • Urology | $369 | $552 | $644 |
| Cystourethroscopy with lithotripsy CPT 52353 • Urology | $518 | $602 | $644 |
| TURP transurethral resection of prostate CPT 52601 • Urology | $518 | $602 | $644 |
| Laser vaporization of prostate CPT 52648 • Urology | $518 | $602 | $644 |
| Circumcision CPT 54150 • Urology | $369 | $552 | $644 |
| Orchiectomy simple CPT 54520 • Urology | $454 | $581 | $644 |
| Orchiectomy radical inguinal CPT 54530 • Urology | $454 | $581 | $644 |
| Vasectomy CPT 55250 • Urology | $369 | $575 | $644 |
| Radical prostatectomy retropubic CPT 55840 • Urology | $298 | $558 | $644 |
| Laparoscopic radical prostatectomy CPT 55866 • Urology | $644 | $668 | $717 |