| Laparoscopic cholecystectomy with cholangiography CPT 47563 • General Surgery | $609 | $609 | $609 |
| Inguinal hernia repair initial CPT 49505 • General Surgery | $438 | $438 | $438 |
| Inguinal hernia repair incarcerated CPT 49507 • General Surgery | $498 | $498 | $498 |
| Thyroid lobectomy with or without isthmusectomy CPT 60220 • General Surgery | $555 | $555 | $555 |
| MRI brain without contrast CPT 70551 • Imaging | $52 | $52 | $52 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $81 | $81 | $81 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $7 | $7 |
| Chest X-ray 2 views CPT 71046 • Imaging | $16 | $16 | $16 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $38 | $38 |
| CT chest with contrast CPT 71260 • Imaging | $44 | $44 | $44 |
| CT angiography chest CPT 71275 • Imaging | $68 | $68 | $68 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $135 | $135 | $135 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $137 | $137 | $137 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $52 | $52 | $52 |
| X-ray shoulder complete CPT 73030 • Imaging | $24 | $24 | $24 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $143 | $143 | $143 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $24 | $24 | $24 |
| X-ray ankle complete CPT 73610 • Imaging | $21 | $21 | $21 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $159 | $159 | $159 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $51 | $51 | $51 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $64 | $64 | $64 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $65 | $65 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $75 | $75 | $75 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $29 | $29 | $29 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $73 | $73 | $73 |
| Ultrasound transvaginal CPT 76830 • Imaging | $79 | $79 | $79 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $71 | $71 | $71 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $31 | $31 | $31 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $37 | $37 | $37 |
| Screening mammography bilateral CPT 77067 • Imaging | $28 | $28 | $28 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $57 | $57 | $57 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $4 | $4 | $4 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $7 | $7 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $7 | $8 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $86 | $86 | $86 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $8 | $8 | $8 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $14 | $18 | $22 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $3 | $4 | $5 |
| Creatinine urine CPT 82570 • Laboratory | $3 | $3 | $3 |
| Ferritin CPT 82728 • Laboratory | $7 | $8 | $10 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $5 | $6 | $7 |
| Iron serum CPT 83540 • Laboratory | $3 | $3 | $3 |
| Iron binding capacity CPT 83550 • Laboratory | $4 | $5 | $7 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $8 | $11 | $14 |