| Parathyroidectomy CPT 60500 • General Surgery | $57 | $2,117 | $5,707 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $308 | $343 | $377 |
| MRI brain without contrast CPT 70551 • Imaging | $195 | $220 | $246 |
| MRI brain with contrast CPT 70552 • Imaging | $361 | $361 | $361 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $377 | $377 | $377 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $21 | $32 |
| Chest X-ray 2 views CPT 71046 • Imaging | $26 | $35 | $44 |
| CT chest without contrast CPT 71250 • Imaging | $111 | $111 | $111 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $179 | $189 |
| CT angiography chest CPT 71275 • Imaging | $189 | $189 | $189 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $233 | $233 | $233 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $234 | $234 | $234 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $235 | $235 | $235 |
| X-ray shoulder complete CPT 73030 • Imaging | $26 | $26 | $26 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $255 | $255 | $255 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $16 | $16 | $16 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $255 | $255 | $255 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $195 | $225 | $255 |
| CT abdomen without contrast CPT 74150 • Imaging | $111 | $111 | $111 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $103 | $150 | $197 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $234 | $305 | $377 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $259 | $259 | $259 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $111 | $111 | $111 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $111 | $111 | $111 |
| Ultrasound transvaginal CPT 76830 • Imaging | $56 | $85 | $111 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $56 | $78 | $111 |
| Screening mammography bilateral CPT 77067 • Imaging | $96 | $96 | $96 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $63 | $615 | $1,394 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $5 | $5 | $5 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $1 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $5 | $5 | $5 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $4 | $4 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $8 | $8 | $8 |
| Amniocentesis diagnostic CPT 59000 • Maternity | $101 | $2,458 | $13,476 |
| Cordocentesis fetal blood sampling CPT 59012 • Maternity | $57 | $244 | $328 |
| Chorionic villus sampling CPT 59015 • Maternity | $57 | $237 | $350 |
| Fetal non-stress test CPT 59025 • Maternity | $38 | $67 | $106 |
| Insertion cervical dilator CPT 59200 • Maternity | $56 | $200 | $350 |
| Vaginal delivery including prenatal and postpartum care CPT 59400 • Maternity | $57 | $171 | $285 |
| Vaginal delivery only CPT 59409 • Maternity | $57 | $885 | $3,354 |
| Vaginal delivery including postpartum care CPT 59410 • Maternity | $57 | $274 | $350 |
| External cephalic version CPT 59412 • Maternity | $57 | $1,394 | $3,275 |
| Antepartum care 7 or more visits CPT 59426 • Maternity | $57 | $171 | $285 |
| Postpartum care only CPT 59430 • Maternity | $57 | $260 | $350 |
| Cesarean delivery including prenatal and postpartum care CPT 59510 • Maternity | $57 | $171 | $285 |
| Cesarean delivery only CPT 59514 • Maternity | $57 | $171 | $285 |
| Cesarean delivery including postpartum care CPT 59515 • Maternity | $57 | $670 | $1,340 |