| CT head without then with contrast CPT 70470 • Imaging | $119 | $119 | $119 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $91 | $91 | $91 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $104 | $104 | $104 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $34 | $129 | $224 |
| CT angiography neck CPT 70498 • Imaging | $87 | $87 | $87 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $359 | $359 | $359 |
| MRI brain without contrast CPT 70551 • Imaging | $50 | $173 | $250 |
| MRI brain with contrast CPT 70552 • Imaging | $250 | $277 | $303 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $62 | $210 | $358 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $17 | $19 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $17 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $34 | $63 | $120 |
| CT chest with contrast CPT 71260 • Imaging | $40 | $51 | $62 |
| CT chest without then with contrast CPT 71270 • Imaging | $34 | $147 | $261 |
| CT angiography chest CPT 71275 • Imaging | $90 | $131 | $171 |
| CT cervical spine without contrast CPT 72125 • Imaging | $122 | $122 | $122 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $121 | $121 | $121 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $120 | $120 | $120 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $50 | $125 | $250 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $40 | $126 | $213 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $212 | $231 | $250 |
| CT pelvis without contrast CPT 72192 • Imaging | $139 | $139 | $139 |
| CT pelvis with contrast CPT 72193 • Imaging | $34 | $95 | $156 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $20 | $29 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $156 | $172 | $187 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $21 | $26 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $23 | $25 | $29 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $67 | $159 | $250 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $40 | $53 | $68 |
| CT abdomen without contrast CPT 74150 • Imaging | $84 | $127 | $171 |
| CT abdomen with contrast CPT 74160 • Imaging | $155 | $155 | $155 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $249 | $249 | $249 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $87 | $129 | $171 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $91 | $127 | $171 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $130 | $171 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $77 | $97 | $117 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $54 | $71 |
| Ultrasound transvaginal CPT 76830 • Imaging | $79 | $103 | $149 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $41 | $47 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $88 | $104 | $134 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $113 | $140 | $168 |
| Screening mammography bilateral CPT 77067 • Imaging | $37 | $70 | $136 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $50 | $225 | $546 |
| 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 | $6 | $7 | $9 |
| Lipid panel CPT 80061 • Laboratory | $9 | $11 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |