| CT maxillofacial without contrast CPT 70486 • Imaging | $311 | $311 | $311 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $375 | $375 | $375 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $87 | $87 | $87 |
| CT angiography neck CPT 70498 • Imaging | $775 | $775 | $775 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $764 | $764 | $764 |
| MRI brain without contrast CPT 70551 • Imaging | $93 | $93 | $93 |
| MRI brain with contrast CPT 70552 • Imaging | $113 | $113 | $113 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $743 | $743 | $743 |
| Chest X-ray single view CPT 71045 • Imaging | $25 | $25 | $25 |
| Chest X-ray 2 views CPT 71046 • Imaging | $24 | $24 | $24 |
| CT chest without contrast CPT 71250 • Imaging | $311 | $311 | $311 |
| CT chest with contrast CPT 71260 • Imaging | $79 | $79 | $79 |
| CT chest without then with contrast CPT 71270 • Imaging | $372 | $372 | $372 |
| CT angiography chest CPT 71275 • Imaging | $121 | $121 | $121 |
| CT cervical spine without contrast CPT 72125 • Imaging | $74 | $74 | $74 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $238 | $238 | $238 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $311 | $311 | $311 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $461 | $461 | $461 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $472 | $472 | $472 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $472 | $472 | $472 |
| CT pelvis without contrast CPT 72192 • Imaging | $294 | $294 | $294 |
| CT pelvis with contrast CPT 72193 • Imaging | $280 | $280 | $280 |
| X-ray shoulder complete CPT 73030 • Imaging | $35 | $35 | $35 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $497 | $497 | $497 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $34 | $34 | $34 |
| X-ray ankle complete CPT 73610 • Imaging | $37 | $37 | $37 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $85 | $85 | $85 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $593 | $593 | $593 |
| CT abdomen without contrast CPT 74150 • Imaging | $223 | $223 | $223 |
| CT abdomen with contrast CPT 74160 • Imaging | $80 | $80 | $80 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $524 | $524 | $524 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $172 | $172 | $172 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $328 | $328 | $328 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $434 | $434 | $434 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $41 | $41 | $41 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $115 | $146 | $172 |
| Ultrasound transvaginal CPT 76830 • Imaging | $115 | $115 | $115 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $35 | $35 | $35 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $127 | $127 | $127 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $162 | $162 | $162 |
| Screening mammography bilateral CPT 77067 • Imaging | $134 | $134 | $134 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $11 | $11 | $11 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $99 | $99 | $99 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $7 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $8 | $9 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $7 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $4 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $4 |