| CT head without then with contrast CPT 70470 • Imaging | $63 | $63 | $63 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $91 | $111 | $131 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $107 | $160 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $34 | $75 | $125 |
| CT angiography neck CPT 70498 • Imaging | $83 | $139 | $194 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $103 | $223 | $379 |
| MRI brain without contrast CPT 70551 • Imaging | $50 | $143 | $250 |
| MRI brain with contrast CPT 70552 • Imaging | $212 | $231 | $250 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $110 | $179 | $241 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $14 | $16 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $16 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $34 | $45 | $58 |
| CT chest with contrast CPT 71260 • Imaging | $40 | $55 | $63 |
| CT chest without then with contrast CPT 71270 • Imaging | $34 | $94 | $154 |
| CT angiography chest CPT 71275 • Imaging | $87 | $152 | $198 |
| CT cervical spine without contrast CPT 72125 • Imaging | $49 | $51 | $53 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $49 | $110 | $172 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $133 | $152 | $172 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $50 | $199 | $340 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $71 | $134 | $212 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $132 | $250 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $69 | $85 |
| CT pelvis with contrast CPT 72193 • Imaging | $34 | $49 | $58 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $24 | $29 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $66 | $67 | $68 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $24 | $31 |
| X-ray ankle complete CPT 73610 • Imaging | $23 | $30 | $40 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $176 | $397 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $40 | $78 | $155 |
| CT abdomen without contrast CPT 74150 • Imaging | $139 | $151 | $171 |
| CT abdomen with contrast CPT 74160 • Imaging | $165 | $165 | $165 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $189 | $226 | $263 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $114 | $171 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $171 | $287 | $536 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $302 | $603 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $76 | $79 | $84 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $26 | $45 | $71 |
| Ultrasound transvaginal CPT 76830 • Imaging | $79 | $105 | $119 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $71 | $89 | $107 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $85 | $134 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $49 | $126 | $168 |
| Screening mammography bilateral CPT 77067 • Imaging | $37 | $85 | $136 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $38 | $39 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $79 | $228 | $305 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $5 | $6 |
| Lipid panel CPT 80061 • Laboratory | $5 | $9 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |