| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $475 | $563 | $650 |
| Total hip replacement CPT 27130 • Orthopedics | $475 | $563 | $650 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $475 | $563 | $650 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $475 | $563 | $650 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $475 | $563 | $650 |
| Treatment intertrochanteric fracture with plate/screw CPT 27245 • Orthopedics | $475 | $563 | $650 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $475 | $563 | $650 |
| Total knee replacement CPT 27447 • Orthopedics | $475 | $563 | $650 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $475 | $563 | $650 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $350 | $500 | $650 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $475 | $563 | $650 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $475 | $563 | $650 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $475 | $563 | $650 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $475 | $563 | $650 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $475 | $563 | $650 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $475 | $563 | $650 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $475 | $563 | $650 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $475 | $563 | $650 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $475 | $563 | $650 |
| Carpal tunnel release CPT 64721 • Orthopedics | $475 | $563 | $650 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $50 | $350 | $650 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $475 | $563 | $650 |
| Epidural injection lumbar or sacral without imaging CPT 62322 • Pain Management | $475 | $563 | $650 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $475 | $563 | $650 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $475 | $563 | $650 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $350 | $500 | $650 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $50 | $350 | $650 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $350 | $500 | $650 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $350 | $500 | $650 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $350 | $413 | $475 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $350 | $413 | $475 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $475 | $475 | $475 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $475 | $563 | $650 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $475 | $563 | $650 |
| Unlisted nervous system procedure CPT 64999 • Pain Management | $475 | $475 | $475 |
| Special stain group II CPT 88313 • Pathology | $62 | $62 | $62 |
| Colorectal cancer screening flexible sigmoidoscopy HCPCS G0104 • Preventive Care | $475 | $563 | $650 |
| Colorectal cancer screening colonoscopy high risk HCPCS G0105 • Preventive Care | $475 | $563 | $650 |
| Colorectal cancer screening colonoscopy not high risk HCPCS G0121 • Preventive Care | $475 | $563 | $650 |
| Bronchoscopy diagnostic CPT 31622 • Pulmonology | $350 | $500 | $650 |
| Bronchoscopy with brushing CPT 31623 • Pulmonology | $475 | $563 | $650 |
| Bronchoscopy with bronchial alveolar lavage CPT 31624 • Pulmonology | $475 | $563 | $650 |
| Bronchoscopy with biopsy CPT 31625 • Pulmonology | $475 | $563 | $650 |
| Bronchoscopy with transbronchial lung biopsy CPT 31628 • Pulmonology | $475 | $563 | $650 |
| Bronchoscopy with endobronchial ultrasound biopsy CPT 31652 • Pulmonology | $475 | $563 | $650 |
| Stereotactic radiosurgery (SRS) cranial CPT 77371 • Radiation Therapy | $2,281 | $2,281 | $2,281 |
| Laparoscopic partial nephrectomy CPT 50543 • Urology | $475 | $563 | $650 |
| Laparoscopic radical nephrectomy CPT 50545 • Urology | $475 | $563 | $650 |
| Lithotripsy extracorporeal shock wave (ESWL) CPT 50590 • Urology | $475 | $563 | $650 |
| Complex uroflowmetry CPT 51741 • Urology | $50 | $50 | $50 |