| Laparoscopic cholecystectomy CPT 47562 • General Surgery | $533 | $597 | $725 |
| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $790 | $790 | $790 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $576 | $576 | $576 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $648 | $648 | $648 |
| Laparoscopic inguinal hernia repair initial CPT 49650 • General Surgery | $476 | $476 | $476 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $783 | $783 | $783 |
| Thyroidectomy total or subtotal CPT 60240 • General Surgery | $1,013 | $1,013 | $1,013 |
| Parathyroidectomy CPT 60500 • General Surgery | $1,069 | $1,069 | $1,069 |
| CT head without contrast CPT 70450 • Imaging | $30 | $30 | $30 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $95 | $95 | $95 |
| CT angiography neck CPT 70498 • Imaging | $62 | $62 | $62 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $355 | $355 | $355 |
| MRI brain without contrast CPT 70551 • Imaging | $52 | $128 | $205 |
| MRI brain with contrast CPT 70552 • Imaging | $87 | $87 | $87 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $81 | $97 | $112 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $19 | $26 |
| Chest X-ray 2 views CPT 71046 • Imaging | $24 | $29 | $34 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $43 | $53 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $85 | $173 |
| CT angiography chest CPT 71275 • Imaging | $64 | $111 | $204 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $35 | $35 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $35 | $35 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $35 | $35 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $52 | $126 | $199 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $73 | $73 | $73 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $52 | $63 | $73 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $51 | $51 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $24 | $27 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $48 | $130 | $211 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $26 | $29 | $34 |
| X-ray ankle complete CPT 73610 • Imaging | $22 | $27 | $31 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $234 | $234 | $234 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $80 | $145 |
| CT abdomen without contrast CPT 74150 • Imaging | $42 | $63 | $84 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $145 | $145 | $145 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $87 | $106 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $119 | $229 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $71 | $165 | $258 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $29 | $73 | $118 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $73 | $78 | $80 |
| Ultrasound transvaginal CPT 76830 • Imaging | $86 | $87 | $88 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $24 | $48 | $73 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $103 | $126 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $130 | $159 |
| Screening mammography bilateral CPT 77067 • Imaging | $27 | $53 | $95 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $78 | $240 | $321 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $5 | $8 |
| Basic metabolic panel CPT 80048 • Laboratory | $8 | $8 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $5 | $10 |