| CT head without then with contrast CPT 70470 • Imaging | $249 | $249 | $249 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $47 | $47 | $47 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $248 | $248 | $248 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $57 | $155 | $254 |
| CT angiography neck CPT 70498 • Imaging | $471 | $471 | $471 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $359 | $460 | $561 |
| MRI brain without contrast CPT 70551 • Imaging | $295 | $322 | $377 |
| MRI brain with contrast CPT 70552 • Imaging | $406 | $450 | $494 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $481 | $569 | $657 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $27 | $33 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $29 | $42 |
| CT chest without contrast CPT 71250 • Imaging | $48 | $138 | $184 |
| CT chest with contrast CPT 71260 • Imaging | $77 | $163 | $249 |
| CT chest without then with contrast CPT 71270 • Imaging | $269 | $288 | $307 |
| CT angiography chest CPT 71275 • Imaging | $301 | $326 | $351 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $48 | $48 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $208 | $208 | $208 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $160 | $160 | $160 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $286 | $326 | $405 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $70 | $70 | $70 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $65 | $177 | $289 |
| CT pelvis without contrast CPT 72192 • Imaging | $153 | $153 | $153 |
| CT pelvis with contrast CPT 72193 • Imaging | $189 | $249 | $309 |
| X-ray shoulder complete CPT 73030 • Imaging | $15 | $40 | $61 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $304 | $359 | $414 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $7 | $34 | $61 |
| X-ray ankle complete CPT 73610 • Imaging | $7 | $29 | $46 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $59 | $198 | $337 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $98 | $275 | $421 |
| CT abdomen without contrast CPT 74150 • Imaging | $192 | $196 | $200 |
| CT abdomen with contrast CPT 74160 • Imaging | $52 | $52 | $52 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $288 | $288 | $288 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $173 | $215 | $256 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $75 | $306 | $430 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $83 | $342 | $481 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $68 | $109 | $150 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $66 | $103 | $139 |
| Ultrasound transvaginal CPT 76830 • Imaging | $60 | $107 | $153 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $61 | $61 | $61 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $51 | $109 | $160 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $101 | $152 | $202 |
| Screening mammography bilateral CPT 77067 • Imaging | $118 | $148 | $163 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $7 | $7 | $7 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $101 | $104 | $106 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $8 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $9 | $10 | $12 |
| Lipid panel CPT 80061 • Laboratory | $9 | $12 | $15 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $8 | $9 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $4 |