| CT head without then with contrast CPT 70470 • Imaging | $63 | $63 | $63 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $60 | $91 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $56 | $56 | $56 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $224 | $266 | $308 |
| CT angiography neck CPT 70498 • Imaging | $30 | $58 | $87 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $194 | $359 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $166 | $240 |
| MRI brain with contrast CPT 70552 • Imaging | $303 | $317 | $331 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $222 | $390 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $23 | $39 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $51 | $164 | $221 |
| CT chest with contrast CPT 71260 • Imaging | $62 | $126 | $189 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $49 | $69 |
| CT angiography chest CPT 71275 • Imaging | $90 | $130 | $169 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $85 | $122 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $76 | $121 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $83 | $127 | $170 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $112 | $233 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $146 | $213 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $159 | $234 |
| CT pelvis without contrast CPT 72192 • Imaging | $54 | $54 | $54 |
| CT pelvis with contrast CPT 72193 • Imaging | $156 | $174 | $192 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $31 | $52 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $206 | $215 | $224 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $30 | $52 |
| X-ray ankle complete CPT 73610 • Imaging | $21 | $23 | $25 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $170 | $277 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $68 | $174 | $247 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $130 | $275 |
| CT abdomen with contrast CPT 74160 • Imaging | $63 | $63 | $63 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $50 | $70 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $192 | $248 | $304 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $295 | $439 | $510 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $415 | $572 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $40 | $114 | $188 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $73 | $117 |
| Ultrasound transvaginal CPT 76830 • Imaging | $117 | $154 | $191 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $68 | $105 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $32 | $58 | $103 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $48 | $149 | $250 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $105 | $130 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $167 | $355 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $9 | $14 | $21 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |