| CT head without then with contrast CPT 70470 • Imaging | $324 | $324 | $324 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $41 | $47 | $53 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $58 | $61 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $187 | $226 | $304 |
| CT angiography neck CPT 70498 • Imaging | $84 | $288 | $492 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $100 | $184 | $348 |
| MRI brain without contrast CPT 70551 • Imaging | $199 | $264 | $456 |
| MRI brain with contrast CPT 70552 • Imaging | $83 | $180 | $276 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $110 | $496 | $882 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $16 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $17 | $31 |
| CT chest without contrast CPT 71250 • Imaging | $52 | $148 | $271 |
| CT chest with contrast CPT 71260 • Imaging | $55 | $128 | $266 |
| CT chest without then with contrast CPT 71270 • Imaging | $64 | $132 | $200 |
| CT angiography chest CPT 71275 • Imaging | $144 | $304 | $511 |
| CT cervical spine without contrast CPT 72125 • Imaging | $49 | $133 | $218 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $49 | $133 | $218 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $49 | $133 | $217 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $71 | $221 | $421 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $194 | $278 | $444 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $191 | $300 | $512 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $51 | $52 |
| CT pelvis with contrast CPT 72193 • Imaging | $54 | $111 | $224 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $27 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $210 | $499 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $21 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $28 | $30 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $248 | $449 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $63 | $134 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $139 | $161 | $206 |
| CT abdomen with contrast CPT 74160 • Imaging | $336 | $336 | $336 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $67 | $249 | $430 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $120 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $88 | $202 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $312 | $450 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $114 | $123 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $34 | $70 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $110 | $119 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $70 | $107 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $93 | $110 | $126 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $51 | $115 | $156 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $70 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $25 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $78 | $358 | $605 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $6 | $8 |
| Lipid panel CPT 80061 • Laboratory | $3 | $7 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |