| 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 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 | $30 | $30 | $30 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $30 | $30 | $30 |
| Parathyroidectomy CPT 60500 • General Surgery | $30 | $30 | $30 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $30 | $30 |
| MRI brain without contrast CPT 70551 • Imaging | $200 | $200 | $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 | $22 | $22 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $134 | $134 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $168 | $168 |
| CT angiography chest CPT 71275 • Imaging | $255 | $255 | $255 |
| 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 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $206 | $206 | $206 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $29 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $32 | $32 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $30 | $30 | $30 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $206 | $206 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $139 | $139 | $139 |
| 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 | $350 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $30 | $30 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $96 | $96 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $105 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $93 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $139 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $112 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $391 | $391 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $8 | $8 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $1 |
| Hemoglobin A1c CPT 83036 • Laboratory | $7 | $7 | $7 |
| Iron binding capacity CPT 83550 • Laboratory | $6 | $6 | $6 |
| Complete blood count with differential CPT 85025 • Laboratory | $6 | $6 | $6 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $10 | $10 | $10 |
| Urine culture bacterial colony count CPT 87086 • Laboratory | $6 | $6 | $6 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $51 | $51 | $51 |