| Hemorrhoidectomy internal by ligation CPT 46221 • General Surgery | $30 | $30 | $30 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $30 | $282 | $533 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $30 | $30 | $30 |
| Inguinal hernia repair initial CPT 49505 • 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 | $30 | $466 | $902 |
| Parathyroidectomy CPT 60500 • General Surgery | $30 | $30 | $30 |
| 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 | $62 | $95 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $30 | $30 |
| CT angiography neck CPT 70498 • Imaging | $30 | $46 | $62 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $30 | $30 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $120 | $200 |
| MRI brain with contrast CPT 70552 • Imaging | $30 | $30 | $30 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $30 | $30 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $20 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $23 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $68 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $48 | $55 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $64 | $160 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $33 | $35 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $33 | $35 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $33 | $35 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $30 | $30 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $113 | $195 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $30 | $30 |
| CT pelvis without contrast CPT 72192 • Imaging | $62 | $62 | $62 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $28 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $206 | $206 | $206 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $26 | $28 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $7 | $21 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $64 | $64 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $95 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $85 | $139 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $88 | $145 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $131 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $230 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $350 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $30 | $30 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $69 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $86 | $95 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $29 | $29 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $104 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $127 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $27 | $73 | $112 |