| CT head without then with contrast CPT 70470 • Imaging | $463 | $463 | $463 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $36 | $42 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $104 | $104 | $104 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $65 | $100 |
| CT angiography neck CPT 70498 • Imaging | $30 | $294 | $558 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $93 | $156 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $276 | $588 |
| MRI brain with contrast CPT 70552 • Imaging | $129 | $203 | $276 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $173 | $376 |
| Chest X-ray single view CPT 71045 • Imaging | $14 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $134 | $193 | $310 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $315 | $461 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $247 | $465 |
| CT angiography chest CPT 71275 • Imaging | $255 | $270 | $285 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $212 | $394 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $75 | $121 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $40 | $50 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $271 | $588 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $84 | $139 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $39 | $103 | $196 |
| CT pelvis without contrast CPT 72192 • Imaging | $389 | $389 | $389 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $44 | $58 |
| X-ray shoulder complete CPT 73030 • Imaging | $13 | $24 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $206 | $215 | $223 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $33 | $40 |
| X-ray ankle complete CPT 73610 • Imaging | $28 | $29 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $372 | $680 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $97 | $170 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $155 | $297 |
| CT abdomen with contrast CPT 74160 • Imaging | $451 | $451 | $451 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $105 | $179 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $131 | $158 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $296 | $307 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $450 | $649 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $133 | $163 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $78 | $108 |
| Ultrasound transvaginal CPT 76830 • Imaging | $35 | $70 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $50 | $50 | $50 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $75 | $104 | $127 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $48 | $94 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $141 | $197 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $147 | $147 | $147 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $415 | $462 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $9 | $17 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $15 | $21 |
| Lipid panel CPT 80061 • Laboratory | $11 | $19 | $27 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $11 | $16 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |