| Laparoscopic gastric bypass (Roux-en-Y) CPT 43644 • General Surgery | $144 | $144 | $144 |
| Laparoscopic gastric band placement CPT 43770 • General Surgery | $369 | $369 | $369 |
| Laparoscopic sleeve gastrectomy CPT 43775 • General Surgery | $571 | $571 | $571 |
| Open appendectomy CPT 44950 • General Surgery | $210 | $210 | $210 |
| Laparoscopic appendectomy CPT 44970 • General Surgery | $44 | $44 | $44 |
| Hemorrhoidectomy internal by ligation CPT 46221 • General Surgery | $93 | $93 | $93 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $344 | $344 | $344 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $52 | $52 | $52 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $274 | $274 | $274 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $307 | $307 | $307 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $143 | $143 | $143 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $59 | $59 | $59 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $301 | $301 | $301 |
| Parathyroidectomy CPT 60500 • General Surgery | $757 | $757 | $757 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $52 | $52 | $52 |
| MRI brain without contrast CPT 70551 • Imaging | $105 | $105 | $105 |
| MRI brain with contrast CPT 70552 • Imaging | $101 | $101 | $101 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $56 | $56 | $56 |
| Chest X-ray single view CPT 71045 • Imaging | $4 | $4 | $4 |
| Chest X-ray 2 views CPT 71046 • Imaging | $5 | $5 | $5 |
| CT chest without contrast CPT 71250 • Imaging | $106 | $106 | $106 |
| CT chest with contrast CPT 71260 • Imaging | $133 | $133 | $133 |
| CT angiography chest CPT 71275 • Imaging | $44 | $44 | $44 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $153 | $153 | $153 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $102 | $102 | $102 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $36 | $36 | $36 |
| X-ray shoulder complete CPT 73030 • Imaging | $5 | $5 | $5 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $33 | $33 | $33 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $18 | $18 | $18 |
| X-ray ankle complete CPT 73610 • Imaging | $19 | $19 | $19 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $33 | $33 | $33 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $75 | $75 | $75 |
| CT abdomen without contrast CPT 74150 • Imaging | $44 | $44 | $44 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $42 | $42 | $42 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $242 | $242 | $242 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $133 | $133 | $133 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $41 | $41 | $41 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $84 | $84 | $84 |
| Ultrasound transvaginal CPT 76830 • Imaging | $45 | $45 | $45 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $82 | $82 | $82 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $98 | $98 | $98 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $82 | $82 | $82 |
| Screening mammography bilateral CPT 77067 • Imaging | $48 | $48 | $48 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $186 | $186 | $186 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $1 | $1 | $1 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $1 | $1 | $1 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $7 | $7 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $5 | $5 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |