| Hemorrhoidectomy internal by ligation CPT 46221 • General Surgery | $635 | $635 | $635 |
| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $1,500 | $1,500 | $1,500 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $1,500 | $2,007 | $2,515 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $1,050 | $1,050 | $1,050 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $1,500 | $1,500 | $1,500 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $1,050 | $1,050 | $1,050 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $700 | $1,695 | $2,690 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $850 | $2,288 | $3,726 |
| Parathyroidectomy CPT 60500 • General Surgery | $850 | $850 | $850 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $308 | $308 | $308 |
| MRI brain without contrast CPT 70551 • Imaging | $195 | $195 | $195 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $10 | $10 |
| Chest X-ray 2 views CPT 71046 • Imaging | $25 | $25 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $111 | $111 | $111 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $168 | $168 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $16 | $21 | $25 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $195 | $195 | $195 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $103 | $103 | $103 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $259 | $259 | $259 |
| Ultrasound transvaginal CPT 76830 • Imaging | $56 | $56 | $56 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $56 | $56 | $56 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $387 | $387 | $387 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $2 | $2 | $2 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $11 | $11 | $11 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $7 | $7 | $7 |
| TB skin test intradermal CPT 86580 • Laboratory | $7 | $7 | $7 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $24 | $24 | $24 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $24 | $24 | $24 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $44 | $44 | $44 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $11 | $11 | $11 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $68 | $68 | $68 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $50 | $50 | $50 |
| Chorionic villus sampling CPT 59015 • Maternity | $50 | $50 | $50 |
| Insertion cervical dilator CPT 59200 • Maternity | $38 | $336 | $635 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $850 | $850 | $850 |
| Vaginal delivery only CPT 59409 • Maternity | $850 | $850 | $850 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $850 | $850 | $850 |
| External cephalic version CPT 59412 • Maternity | $635 | $635 | $635 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $847 | $847 | $847 |
| Postpartum care only CPT 59430 • Maternity | $220 | $220 | $220 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $850 | $850 | $850 |
| Cesarean delivery only CPT 59514 • Maternity | $850 | $850 | $850 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $850 | $850 | $850 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $523 | $687 | $850 |
| Obstetric ultrasound first trimester CPT 76801 • Maternity | $88 | $88 | $88 |
| Obstetric ultrasound complete CPT 76805 • Maternity | $56 | $78 | $101 |
| Obstetric ultrasound limited CPT 76815 • Maternity | $61 | $61 | $61 |
| Ultrasound transvaginal obstetric CPT 76817 • Maternity | $36 | $36 | $36 |