| CT head without then with contrast CPT 70470 • Imaging | $184 | $184 | $184 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $75 | $119 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $161 | $161 | $161 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $127 | $159 | $192 |
| CT angiography neck CPT 70498 • Imaging | $30 | $199 | $367 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $209 | $388 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $117 | $194 |
| MRI brain with contrast CPT 70552 • Imaging | $287 | $287 | $287 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $197 | $363 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $18 | $21 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $118 | $205 |
| CT chest with contrast CPT 71260 • Imaging | $166 | $166 | $166 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $163 | $296 |
| CT angiography chest CPT 71275 • Imaging | $119 | $119 | $119 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $42 | $53 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $40 | $50 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $40 | $50 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $63 | $97 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $157 | $284 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $52 | $74 |
| CT pelvis without contrast CPT 72192 • Imaging | $71 | $71 | $71 |
| CT pelvis with contrast CPT 72193 • Imaging | $58 | $125 | $192 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $33 | $37 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $228 | $228 | $228 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $30 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $28 | $29 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $294 | $294 | $294 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $160 | $183 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $45 | $59 |
| CT abdomen with contrast CPT 74160 • Imaging | $290 | $290 | $290 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $106 | $182 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $113 | $113 | $113 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $192 | $246 | $299 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $192 | $265 | $339 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $119 | $119 | $119 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $39 | $48 |
| Ultrasound transvaginal CPT 76830 • Imaging | $154 | $154 | $154 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $45 | $45 | $45 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $53 | $78 | $103 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $215 | $215 | $215 |
| Screening mammography bilateral CPT 77067 • Imaging | $105 | $139 | $173 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $30 | $30 | $30 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $355 | $412 | $469 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $8 | $9 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |