| CT head without then with contrast CPT 70470 • Imaging | $200 | $200 | $200 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $101 | $147 | $192 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $114 | $114 | $114 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $75 | $134 | $192 |
| CT angiography neck CPT 70498 • Imaging | $192 | $255 | $318 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $275 | $345 | $416 |
| MRI brain without contrast CPT 70551 • Imaging | $147 | $209 | $240 |
| MRI brain with contrast CPT 70552 • Imaging | $216 | $273 | $331 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $244 | $318 | $391 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $17 | $21 |
| Chest X-ray 2 views CPT 71046 • Imaging | $12 | $21 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $74 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $129 | $129 | $129 |
| CT chest without then with contrast CPT 71270 • Imaging | $192 | $209 | $226 |
| CT angiography chest CPT 71275 • Imaging | $226 | $250 | $275 |
| CT cervical spine without contrast CPT 72125 • Imaging | $96 | $144 | $192 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $150 | $171 | $192 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $95 | $143 | $192 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $221 | $229 | $234 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $140 | $202 | $234 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $47 | $141 | $234 |
| CT pelvis without contrast CPT 72192 • Imaging | $154 | $154 | $154 |
| CT pelvis with contrast CPT 72193 • Imaging | $192 | $228 | $263 |
| X-ray shoulder complete CPT 73030 • Imaging | $10 | $22 | $28 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $74 | $121 | $168 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $21 | $28 |
| X-ray ankle complete CPT 73610 • Imaging | $10 | $20 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $73 | $73 | $73 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $117 | $247 |
| CT abdomen without contrast CPT 74150 • Imaging | $65 | $177 | $275 |
| CT abdomen with contrast CPT 74160 • Imaging | $69 | $69 | $69 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $192 | $247 | $302 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $94 | $185 | $275 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $99 | $189 | $275 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $192 | $250 | $283 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $44 | $69 | $95 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $89 | $100 | $122 |
| Ultrasound transvaginal CPT 76830 • Imaging | $98 | $116 | $134 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $81 | $87 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $70 | $95 | $141 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $54 | $92 | $129 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $94 | $144 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $33 | $33 | $33 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $87 | $277 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $5 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $4 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $4 | $4 |
| Lipid panel CPT 80061 • Laboratory | $5 | $5 | $6 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |