| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $961 | $961 | $961 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $1,212 | $1,212 | $1,212 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $340 | $340 | $340 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $180 | $180 | $180 |
| MRI brain without contrast CPT 70551 • Imaging | $600 | $600 | $600 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $180 | $180 | $180 |
| Chest X-ray single view CPT 71045 • Imaging | $19 | $19 | $20 |
| Chest X-ray 2 views CPT 71046 • Imaging | $10 | $10 | $10 |
| CT chest without contrast CPT 71250 • Imaging | $268 | $268 | $268 |
| CT chest with contrast CPT 71260 • Imaging | $50 | $50 | $50 |
| CT chest without then with contrast CPT 71270 • Imaging | $420 | $420 | $420 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $600 | $600 | $600 |
| CT pelvis with contrast CPT 72193 • Imaging | $324 | $324 | $324 |
| X-ray shoulder complete CPT 73030 • Imaging | $50 | $50 | $50 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $50 | $50 | $50 |
| X-ray ankle complete CPT 73610 • Imaging | $50 | $50 | $50 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $420 | $510 | $600 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $235 | $235 | $235 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $371 | $371 | $372 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $471 | $471 | $471 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $135 | $135 | $135 |
| Ultrasound transvaginal CPT 76830 • Imaging | $125 | $125 | $125 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $91 | $91 | $91 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $93 | $113 | $132 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $167 | $167 | $167 |
| Screening mammography bilateral CPT 77067 • Imaging | $135 | $135 | $136 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $478 | $478 | $478 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $8 | $8 | $8 |
| Lipid panel CPT 80061 • Laboratory | $13 | $13 | $14 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $3 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $16 | $16 | $16 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $31 | $31 | $31 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $6 | $6 | $7 |
| Ferritin CPT 82728 • Laboratory | $14 | $14 | $14 |
| Iron binding capacity CPT 83550 • Laboratory | $9 | $9 | $9 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $19 | $19 | $19 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $6 | $6 | $6 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $13 | $13 | $13 |
| TB skin test intradermal CPT 86580 • Laboratory | $6 | $6 | $6 |
| Blood typing ABO CPT 86900 • Laboratory | $3 | $3 | $3 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $36 | $36 | $36 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $12 | $12 | $12 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $254 | $254 | $254 |
| Fetal non-stress test CPT 59025 • Maternity | $58 | $58 | $58 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $2,350 | $2,350 | $2,350 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $50 | $602 | $1,155 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $2,350 | $2,350 | $2,350 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $1,399 | $1,399 | $1,399 |
| Vaginal delivery after prior cesarean (VBAC) including prenatal CPT 59610 • Maternity | $50 | $50 | $50 |
| Obstetric ultrasound detailed fetal anatomy CPT 76811 • Maternity | $191 | $191 | $191 |