| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $697 | $697 | $697 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $409 | $409 | $409 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $518 | $518 | $518 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $380 | $380 | $380 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $669 | $669 | $669 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $977 | $977 | $977 |
| Parathyroidectomy CPT 60500 • General Surgery | $961 | $961 | $961 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $891 | $891 | $891 |
| MRI brain without contrast CPT 70551 • Imaging | $409 | $409 | $409 |
| MRI brain with contrast CPT 70552 • Imaging | $93 | $93 | $93 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $122 | $122 | $122 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $9 | $9 |
| Chest X-ray 2 views CPT 71046 • Imaging | $18 | $18 | $18 |
| CT chest without contrast CPT 71250 • Imaging | $60 | $60 | $60 |
| CT chest with contrast CPT 71260 • Imaging | $64 | $64 | $64 |
| CT angiography chest CPT 71275 • Imaging | $318 | $318 | $318 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $83 | $83 | $83 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $454 | $454 | $454 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $77 | $77 | $77 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $21 | $21 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $51 | $51 | $51 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $19 | $19 | $19 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $9 | $9 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $50 | $50 | $50 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $406 | $406 | $406 |
| CT abdomen without contrast CPT 74150 • Imaging | $62 | $62 | $62 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $126 | $126 | $126 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $87 | $87 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $319 | $319 | $319 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $42 | $42 | $42 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $38 | $38 | $38 |
| Ultrasound transvaginal CPT 76830 • Imaging | $56 | $56 | $56 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $56 | $56 | $56 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $39 | $39 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $48 | $48 | $48 |
| Screening mammography bilateral CPT 77067 • Imaging | $93 | $93 | $93 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $76 | $76 | $76 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $3 | $3 | $3 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $7 | $7 | $7 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $32 | $32 | $32 |
| Basic metabolic panel CPT 80048 • Laboratory | $9 | $9 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $10 | $10 | $10 |
| Lipid panel CPT 80061 • Laboratory | $16 | $16 | $16 |
| Hepatic function panel CPT 80076 • Laboratory | $9 | $9 | $9 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $9 | $9 | $9 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $7 | $7 | $7 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $21 | $21 | $21 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $35 | $35 | $35 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $8 | $8 | $8 |
| Creatinine urine CPT 82570 • Laboratory | $6 | $6 | $6 |