| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $665 | $665 | $665 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $546 | $546 | $546 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $403 | $403 | $403 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $642 | $642 | $642 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $830 | $830 | $830 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $225 | $225 | $225 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $215 | $215 | $215 |
| MRI brain without contrast CPT 70551 • Imaging | $375 | $375 | $375 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $88 | $88 | $88 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $21 | $27 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $15 | $15 |
| CT chest without contrast CPT 71250 • Imaging | $163 | $163 | $163 |
| CT chest without then with contrast CPT 71270 • Imaging | $240 | $240 | $240 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $375 | $375 | $375 |
| CT pelvis with contrast CPT 72193 • Imaging | $277 | $277 | $277 |
| X-ray shoulder complete CPT 73030 • Imaging | $36 | $36 | $36 |
| X-ray ankle complete CPT 73610 • Imaging | $5 | $21 | $38 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $196 | $196 | $196 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $52 | $214 | $375 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $159 | $159 | $159 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $271 | $320 | $369 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $304 | $359 | $414 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $48 | $48 | $48 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $130 | $130 | $130 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $103 | $103 | $103 |
| Screening mammography bilateral CPT 77067 • Imaging | $37 | $85 | $133 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $77 | $77 | $77 |
| Lipid panel CPT 80061 • Laboratory | $8 | $8 | $9 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $2 | $2 | $2 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $20 | $20 | $20 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $1 | $1 | $1 |
| Ferritin CPT 82728 • Laboratory | $2 | $5 | $9 |
| Iron binding capacity CPT 83550 • Laboratory | $3 | $3 | $3 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $4 | $4 | $4 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $6 | $6 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $21 | $21 | $21 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $21 | $21 | $21 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $6 | $7 | $9 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $155 | $155 | $155 |
| Fetal non-stress test CPT 59025 • Maternity | $38 | $38 | $38 |
| Insertion cervical dilator CPT 59200 • Maternity | $43 | $43 | $43 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $836 | $836 | $836 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $1,950 | $1,950 | $1,950 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $83 | $83 | $83 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $95 | $95 | $95 |
| Interactive complexity add-on CPT 90785 • Mental Health | $12 | $16 | $20 |
| Psychiatric diagnostic evaluation CPT 90791 • Mental Health | $127 | $147 | $166 |
| Psychiatric diagnostic evaluation with medical services CPT 90792 • Mental Health | $140 | $162 | $180 |