| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $30 | $282 | $533 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $30 | $426 | $822 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $599 | $599 | $599 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $674 | $674 | $674 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $496 | $496 | $496 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $30 | $359 | $688 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $891 | $891 | $892 |
| Parathyroidectomy CPT 60500 • General Surgery | $944 | $944 | $944 |
| 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 | $169 | $169 | $169 |
| 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 | $85 | $255 | $425 |
| MRI brain with contrast CPT 70552 • Imaging | $425 | $425 | $425 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $30 | $30 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $18 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $15 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $94 | $122 |
| CT chest with contrast CPT 71260 • Imaging | $30 | $36 | $41 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $64 | $149 | $233 |
| 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 | $85 | $255 | $425 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $30 | $30 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $228 | $425 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $51 | $51 |
| CT pelvis with contrast CPT 72193 • Imaging | $206 | $206 | $206 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $27 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $65 | $65 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $26 | $29 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $26 | $30 | $33 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $64 | $64 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $54 | $85 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $77 | $124 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $88 | $145 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $122 | $167 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $209 | $282 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $315 | $315 | $315 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $103 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $69 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $86 | $96 | $106 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $65 | $65 | $65 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $78 | $94 | $111 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $128 | $140 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $98 | $114 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |