| CT maxillofacial without contrast CPT 70486 • Imaging | $34 | $34 | $34 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $191 | $191 | $191 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $147 | $228 | $309 |
| CT angiography neck CPT 70498 • Imaging | $312 | $364 | $415 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $410 | $432 | $454 |
| MRI brain without contrast CPT 70551 • Imaging | $320 | $341 | $362 |
| MRI brain with contrast CPT 70552 • Imaging | $53 | $277 | $501 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $70 | $331 | $591 |
| Chest X-ray single view CPT 71045 • Imaging | $12 | $29 | $45 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $15 | $18 |
| CT chest without contrast CPT 71250 • Imaging | $139 | $173 | $221 |
| CT chest with contrast CPT 71260 • Imaging | $37 | $67 | $96 |
| CT chest without then with contrast CPT 71270 • Imaging | $237 | $237 | $237 |
| CT angiography chest CPT 71275 • Imaging | $235 | $349 | $463 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $35 | $35 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $126 | $126 | $126 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $160 | $160 | $160 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $245 | $300 | $354 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $123 | $212 | $300 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $252 | $303 | $354 |
| CT pelvis without contrast CPT 72192 • Imaging | $120 | $120 | $120 |
| CT pelvis with contrast CPT 72193 • Imaging | $148 | $148 | $148 |
| X-ray shoulder complete CPT 73030 • Imaging | $11 | $42 | $61 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $40 | $207 | $374 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $16 | $34 | $60 |
| X-ray ankle complete CPT 73610 • Imaging | $17 | $42 | $59 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $311 | $364 | $416 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $305 | $339 | $374 |
| CT abdomen without contrast CPT 74150 • Imaging | $154 | $211 | $251 |
| CT abdomen with contrast CPT 74160 • Imaging | $38 | $38 | $38 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $226 | $308 | $389 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $79 | $207 | $334 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $121 | $280 | $569 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $199 | $472 | $637 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $77 | $143 | $209 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $22 | $130 | $193 |
| Ultrasound transvaginal CPT 76830 • Imaging | $20 | $117 | $213 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $68 | $128 | $188 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $48 | $108 | $222 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $69 | $175 | $281 |
| Screening mammography bilateral CPT 77067 • Imaging | $57 | $114 | $226 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $6 | $6 | $6 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $72 | $528 | $793 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $1 | $4 | $6 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $8 | $8 | $8 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $4 | $5 |