| CT head without then with contrast CPT 70470 • Imaging | $155 | $155 | $155 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $41 | $47 | $53 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $94 | $134 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $177 | $247 |
| CT angiography neck CPT 70498 • Imaging | $84 | $223 | $361 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $103 | $319 | $510 |
| MRI brain without contrast CPT 70551 • Imaging | $71 | $212 | $294 |
| MRI brain with contrast CPT 70552 • Imaging | $110 | $110 | $110 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $110 | $297 | $478 |
| Chest X-ray single view CPT 71045 • Imaging | $11 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $21 | $30 | $40 |
| CT chest without contrast CPT 71250 • Imaging | $52 | $122 | $157 |
| CT chest with contrast CPT 71260 • Imaging | $63 | $166 | $239 |
| CT chest without then with contrast CPT 71270 • Imaging | $198 | $215 | $231 |
| CT angiography chest CPT 71275 • Imaging | $112 | $128 | $144 |
| CT cervical spine without contrast CPT 72125 • Imaging | $49 | $88 | $128 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $49 | $119 | $190 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $49 | $88 | $127 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $71 | $207 | $286 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $183 | $214 | $265 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $82 | $91 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $59 | $67 |
| CT pelvis with contrast CPT 72193 • Imaging | $55 | $130 | $263 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $31 | $40 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $172 | $280 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $25 | $27 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $7 | $25 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $161 | $336 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $203 | $272 | $303 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $119 | $182 |
| CT abdomen with contrast CPT 74160 • Imaging | $223 | $223 | $223 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $86 | $175 | $263 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $184 | $214 | $244 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $274 | $360 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $338 | $448 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $84 | $117 | $150 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $45 | $63 | $80 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $71 | $108 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $63 | $87 | $107 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $33 | $86 | $164 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $62 | $119 | $160 |
| Screening mammography bilateral CPT 77067 • Imaging | $111 | $117 | $126 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $40 | $44 | $48 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $78 | $292 | $485 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $5 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $6 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $8 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $3 | $3 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $2 |