| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $30 | $36 | $42 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $30 | $522 | $1,013 |
| Parathyroidectomy CPT 60500 • General Surgery | $1,066 | $1,066 | $1,066 |
| 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 | $30 | $30 | $30 |
| 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 | $40 | $205 | $370 |
| MRI brain with contrast CPT 70552 • Imaging | $370 | $370 | $370 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $36 | $42 |
| Chest X-ray single view CPT 71045 • Imaging | $15 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $19 | $19 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $49 | $67 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $168 | $168 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $309 | $309 | $309 |
| 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 | $30 | $200 | $370 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $36 | $42 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $71 | $220 | $370 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $22 | $26 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $42 | $42 | $42 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $24 | $27 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $36 | $42 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $64 | $64 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $30 | $30 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $92 | $153 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $205 | $205 | $205 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $317 | $321 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $351 | $357 | $364 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $95 | $95 | $95 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $59 | $88 |
| Ultrasound transvaginal CPT 76830 • Imaging | $95 | $95 | $95 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $42 | $42 | $42 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $34 | $72 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $132 | $132 | $132 |
| Screening mammography bilateral CPT 77067 • Imaging | $78 | $95 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $320 | $356 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $8 | $8 |
| Lipid panel CPT 80061 • Laboratory | $11 | $11 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $5 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |