| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $406 | $406 | $406 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $639 | $639 | $639 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $830 | $830 | $830 |
| 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 | $180 | $180 | $180 |
| CT angiography neck CPT 70498 • Imaging | $30 | $30 | $30 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $30 | $30 |
| MRI brain without contrast CPT 70551 • Imaging | $202 | $202 | $202 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $30 | $30 |
| Chest X-ray single view CPT 71045 • Imaging | $22 | $22 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $19 | $19 |
| CT chest without contrast CPT 71250 • Imaging | $129 | $129 | $129 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| 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 | $198 | $198 | $198 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $78 | $126 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $30 | $30 |
| CT pelvis with contrast CPT 72193 • Imaging | $215 | $215 | $215 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $30 | $30 | $30 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $30 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $31 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $167 | $167 | $167 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $119 | $208 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $30 | $30 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $178 | $178 | $178 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $300 | $300 | $301 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $336 | $336 | $337 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $30 | $30 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $30 | $30 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $139 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $96 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $390 | $390 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $10 | $10 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $3 | $3 | $3 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $24 | $24 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Ferritin CPT 82728 • Laboratory | $11 | $11 | $11 |