| Laparoscopic fundoplasty CPT 43280 • General Surgery | $30 | $30 | $30 |
| Laparoscopic gastric bypass (Roux-en-Y) CPT 43644 • General Surgery | $1,709 | $1,709 | $1,709 |
| Laparoscopic gastric band placement CPT 43770 • General Surgery | $1,110 | $1,110 | $1,110 |
| Laparoscopic sleeve gastrectomy CPT 43775 • General Surgery | $1,092 | $1,092 | $1,092 |
| Open appendectomy CPT 44950 • General Surgery | $30 | $30 | $30 |
| Laparoscopic appendectomy CPT 44970 • General Surgery | $30 | $30 | $30 |
| Hemorrhoidectomy internal by ligation CPT 46221 • General Surgery | $30 | $30 | $30 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $30 | $30 | $30 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $30 | $30 | $30 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $30 | $30 | $30 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $30 | $30 | $30 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $694 | $694 | $694 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $902 | $902 | $902 |
| CT head without contrast CPT 70450 • Imaging | $30 | $30 | $30 |
| CT head with contrast CPT 70460 • Imaging | $30 | $30 | $30 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $30 | $30 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $30 | $30 |
| CT angiography neck CPT 70498 • Imaging | $30 | $30 | $30 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $189 | $348 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $40 | $40 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $69 | $108 |
| Chest X-ray single view CPT 71045 • Imaging | $22 | $22 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $82 | $134 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $30 | $30 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $30 | $30 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $30 | $30 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $30 | $30 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $30 | $30 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $30 | $30 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $30 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $30 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $7 | $19 | $30 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $65 | $136 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $30 | $30 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $185 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $313 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $350 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $103 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $30 | $30 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $105 | $105 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $75 | $93 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $139 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $96 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $230 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $7 | $7 |