| CT head without then with contrast CPT 70470 • Imaging | $199 | $199 | $199 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $37 | $44 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $253 | $253 | $253 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $183 | $215 | $247 |
| CT angiography neck CPT 70498 • Imaging | $30 | $49 | $68 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $56 | $82 |
| MRI brain without contrast CPT 70551 • Imaging | $400 | $446 | $525 |
| MRI brain with contrast CPT 70552 • Imaging | $69 | $297 | $525 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $296 | $489 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $18 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $19 | $23 |
| CT chest without contrast CPT 71250 • Imaging | $131 | $154 | $200 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $208 | $249 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $141 | $252 |
| CT angiography chest CPT 71275 • Imaging | $74 | $183 | $291 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $96 | $162 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $35 | $39 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $35 | $39 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $373 | $433 | $525 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $206 | $525 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $290 | $525 |
| CT pelvis without contrast CPT 72192 • Imaging | $152 | $152 | $152 |
| CT pelvis with contrast CPT 72193 • Imaging | $45 | $134 | $224 |
| X-ray shoulder complete CPT 73030 • Imaging | $25 | $27 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $338 | $338 | $338 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $17 | $25 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $19 | $29 | $36 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $406 | $406 | $406 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $345 | $373 | $400 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $75 | $150 |
| CT abdomen with contrast CPT 74160 • Imaging | $267 | $267 | $267 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $192 | $353 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $171 | $186 | $201 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $202 | $276 | $320 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $342 | $349 | $361 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $31 | $69 | $108 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $69 | $100 |
| Ultrasound transvaginal CPT 76830 • Imaging | $73 | $91 | $108 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $31 | $52 | $73 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $101 | $110 | $119 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $128 | $140 | $151 |
| Screening mammography bilateral CPT 77067 • Imaging | $87 | $101 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $78 | $78 | $78 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $60 | $174 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $1 | $2 | $2 |
| 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 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |