| CT head without then with contrast CPT 70470 • Imaging | $83 | $83 | $83 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $131 | $160 | $190 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $189 | $324 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $181 | $293 |
| CT angiography neck CPT 70498 • Imaging | $83 | $413 | $742 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $103 | $124 | $144 |
| MRI brain without contrast CPT 70551 • Imaging | $199 | $338 | $425 |
| MRI brain with contrast CPT 70552 • Imaging | $421 | $423 | $425 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $110 | $245 | $497 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $15 | $20 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $24 | $31 |
| CT chest without contrast CPT 71250 • Imaging | $52 | $182 | $231 |
| CT chest with contrast CPT 71260 • Imaging | $56 | $125 | $237 |
| CT chest without then with contrast CPT 71270 • Imaging | $224 | $293 | $362 |
| CT angiography chest CPT 71275 • Imaging | $87 | $303 | $413 |
| CT cervical spine without contrast CPT 72125 • Imaging | $49 | $97 | $145 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $49 | $130 | $212 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $133 | $259 | $386 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $33 | $189 | $425 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $194 | $471 | $749 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $413 | $741 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $62 | $71 |
| CT pelvis with contrast CPT 72193 • Imaging | $56 | $232 | $361 |
| X-ray shoulder complete CPT 73030 • Imaging | $27 | $31 | $33 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $225 | $313 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $26 | $32 |
| X-ray ankle complete CPT 73610 • Imaging | $26 | $36 | $44 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $281 | $425 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $33 | $114 | $208 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $164 | $233 |
| CT abdomen with contrast CPT 74160 • Imaging | $338 | $338 | $338 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $263 | $373 | $482 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $134 | $202 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $305 | $348 | $446 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $264 | $405 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $84 | $129 | $166 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $36 | $92 | $134 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $94 | $127 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $35 | $63 | $107 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $93 | $137 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $160 | $169 | $174 |
| Screening mammography bilateral CPT 77067 • Imaging | $106 | $140 | $187 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $40 | $87 | $133 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $80 | $187 | $319 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $8 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $7 | $9 |
| Lipid panel CPT 80061 • Laboratory | $6 | $10 | $15 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $8 | $9 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $3 | $3 |