| CT head without then with contrast CPT 70470 • Imaging | $139 | $139 | $139 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $68 | $105 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $56 | $56 | $56 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $124 | $187 |
| CT angiography neck CPT 70498 • Imaging | $30 | $167 | $279 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $68 | $107 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $172 | $248 |
| MRI brain with contrast CPT 70552 • Imaging | $30 | $186 | $343 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $236 | $359 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $18 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $20 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $37 | $51 |
| CT chest with contrast CPT 71260 • Imaging | $169 | $193 | $217 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $55 | $80 |
| CT angiography chest CPT 71275 • Imaging | $30 | $68 | $105 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $102 | $173 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $102 | $173 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $100 | $170 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $67 | $139 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $121 | $195 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $127 | $196 |
| CT pelvis without contrast CPT 72192 • Imaging | $162 | $162 | $162 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $116 | $201 |
| X-ray shoulder complete CPT 73030 • Imaging | $18 | $25 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $209 | $216 | $223 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $28 | $35 | $52 |
| X-ray ankle complete CPT 73610 • Imaging | $10 | $22 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $226 | $285 | $344 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $176 | $199 | $208 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $113 | $143 |
| CT abdomen with contrast CPT 74160 • Imaging | $200 | $200 | $200 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $129 | $228 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $137 | $171 | $192 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $305 | $324 | $363 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $286 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $75 | $116 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $54 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $35 | $86 | $119 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $86 | $122 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $119 | $127 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $153 | $162 |
| Screening mammography bilateral CPT 77067 • Imaging | $68 | $103 | $152 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $407 | $527 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $5 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $6 | $8 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |