| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $30 | $30 | $30 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $30 | $439 | $848 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $617 | $617 | $617 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $694 | $694 | $695 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $30 | $270 | $510 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $737 | $737 | $737 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $955 | $955 | $955 |
| Parathyroidectomy CPT 60500 • General Surgery | $1,008 | $1,008 | $1,008 |
| 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 | $192 | $192 | $192 |
| CT angiography neck CPT 70498 • Imaging | $30 | $30 | $30 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $161 | $291 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $140 | $240 |
| MRI brain with contrast CPT 70552 • Imaging | $331 | $331 | $331 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $144 | $258 |
| Chest X-ray single view CPT 71045 • Imaging | $21 | $21 | $21 |
| Chest X-ray 2 views CPT 71046 • Imaging | $18 | $18 | $18 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $111 | $192 |
| CT chest with contrast CPT 71260 • Imaging | $275 | $275 | $275 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $275 | $275 | $275 |
| 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 | $132 | $233 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $132 | $233 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $132 | $234 |
| CT pelvis with contrast CPT 72193 • Imaging | $192 | $192 | $192 |
| X-ray shoulder complete CPT 73030 • Imaging | $28 | $29 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $247 | $247 | $247 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $27 | $29 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $22 | $26 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $64 | $64 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $168 | $208 | $247 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $153 | $275 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $275 | $275 | $275 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $192 | $234 | $275 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $192 | $234 | $275 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $95 | $95 | $95 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $60 | $89 |
| Ultrasound transvaginal CPT 76830 • Imaging | $98 | $98 | $98 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $27 | $27 | $27 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $70 | $86 | $103 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $129 | $129 | $129 |
| Screening mammography bilateral CPT 77067 • Imaging | $30 | $67 | $105 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $64 | $209 | $355 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $6 | $6 | $7 |