| Auto-added CPT 99496 • General | $250 | $250 | $250 |
| Breast biopsy with stereotactic guidance CPT 19081 • General Surgery | $168 | $168 | $168 |
| Excision breast lesion CPT 19120 • General Surgery | $585 | $585 | $585 |
| Partial mastectomy CPT 19301 • General Surgery | $660 | $660 | $660 |
| Simple complete mastectomy CPT 19303 • General Surgery | $133 | $133 | $133 |
| Biopsy or excision lymph node open superficial CPT 38500 • General Surgery | $128 | $128 | $128 |
| Biopsy or excision lymph node open deep CPT 38525 • General Surgery | $224 | $224 | $224 |
| Laparoscopic lymphadenectomy pelvic CPT 38571 • General Surgery | $342 | $342 | $342 |
| Laparoscopic appendectomy CPT 44970 • General Surgery | $82 | $82 | $82 |
| Hemorrhoidectomy internal by ligation CPT 46221 • General Surgery | $327 | $327 | $327 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $90 | $90 | $90 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $97 | $97 | $97 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $773 | $773 | $773 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $675 | $675 | $675 |
| Parathyroidectomy CPT 60500 • General Surgery | $1,153 | $1,153 | $1,153 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $94 | $94 | $94 |
| MRI brain without contrast CPT 70551 • Imaging | $64 | $64 | $64 |
| MRI brain with contrast CPT 70552 • Imaging | $158 | $158 | $158 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $85 | $85 | $85 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $8 | $8 |
| Chest X-ray 2 views CPT 71046 • Imaging | $8 | $8 | $8 |
| CT chest without contrast CPT 71250 • Imaging | $47 | $47 | $47 |
| CT chest with contrast CPT 71260 • Imaging | $43 | $43 | $43 |
| CT angiography chest CPT 71275 • Imaging | $79 | $186 | $292 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $55 | $55 | $55 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $65 | $65 | $65 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $56 | $56 | $56 |
| X-ray shoulder complete CPT 73030 • Imaging | $18 | $18 | $18 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $51 | $51 | $51 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $23 | $23 | $23 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $8 | $8 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $50 | $50 | $50 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $60 | $60 | $60 |
| CT abdomen without contrast CPT 74150 • Imaging | $44 | $44 | $44 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $76 | $76 | $76 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $80 | $80 | $80 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $74 | $74 | $74 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $77 | $77 | $77 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $32 | $32 | $32 |
| Ultrasound transvaginal CPT 76830 • Imaging | $100 | $121 | $141 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $31 | $95 | $160 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $31 | $31 | $31 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $113 | $113 | $113 |
| Screening mammography bilateral CPT 77067 • Imaging | $33 | $33 | $33 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $71 | $71 | $71 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $5 | $8 | $11 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $4 | $7 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $10 | $10 | $10 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $4 | $4 |