| Laparoscopic sleeve gastrectomy CPT 43775 • General Surgery | $189 | $189 | $189 |
| Open appendectomy CPT 44950 • General Surgery | $30 | $30 | $30 |
| Laparoscopic appendectomy CPT 44970 • General Surgery | $30 | $389 | $748 |
| Hemorrhoidectomy internal by ligation CPT 46221 • General Surgery | $30 | $30 | $30 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $30 | $425 | $819 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $30 | $460 | $891 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $647 | $647 | $647 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $30 | $30 | $30 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $30 | $415 | $799 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $694 | $787 | $879 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $902 | $902 | $902 |
| CT head without contrast CPT 70450 • Imaging | $30 | $42 | $54 |
| CT head with contrast CPT 70460 • Imaging | $30 | $51 | $72 |
| CT head without then with contrast CPT 70470 • Imaging | $80 | $80 | $80 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $42 | $54 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $71 | $71 | $71 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $59 | $87 |
| CT angiography neck CPT 70498 • Imaging | $30 | $70 | $111 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $83 | $135 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $111 | $182 |
| MRI brain with contrast CPT 70552 • Imaging | $113 | $113 | $113 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $87 | $144 |
| Chest X-ray single view CPT 71045 • Imaging | $12 | $17 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $21 | $21 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $75 | $120 |
| CT chest with contrast CPT 71260 • Imaging | $80 | $80 | $80 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $59 | $87 |
| CT angiography chest CPT 71275 • Imaging | $115 | $115 | $115 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $49 | $68 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $47 | $63 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $81 | $133 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $62 | $94 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $62 | $94 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $103 | $175 |
| CT pelvis without contrast CPT 72192 • Imaging | $69 | $69 | $69 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $52 | $74 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $31 | $31 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $86 | $86 | $86 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $28 | $29 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $29 | $30 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $85 | $85 | $85 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $86 | $146 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $53 | $75 |
| CT abdomen with contrast CPT 74160 • Imaging | $80 | $80 | $80 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $59 | $88 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $135 | $135 | $135 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $115 | $214 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $127 | $239 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $97 | $97 | $97 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $54 | $77 |