| CT head without then with contrast CPT 70470 • Imaging | $171 | $171 | $171 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $86 | $117 | $171 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $150 | $150 | $150 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $65 | $118 | $171 |
| CT angiography neck CPT 70498 • Imaging | $62 | $105 | $171 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $100 | $158 | $188 |
| MRI brain without contrast CPT 70551 • Imaging | $69 | $148 | $188 |
| MRI brain with contrast CPT 70552 • Imaging | $187 | $227 | $267 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $188 | $251 | $314 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $12 | $16 |
| Chest X-ray 2 views CPT 71046 • Imaging | $7 | $22 | $32 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $102 | $171 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $76 | $110 |
| CT chest without then with contrast CPT 71270 • Imaging | $58 | $115 | $171 |
| CT angiography chest CPT 71275 • Imaging | $64 | $128 | $192 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $96 | $171 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $84 | $171 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $84 | $171 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $69 | $148 | $188 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $69 | $148 | $188 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $70 | $148 | $188 |
| CT pelvis without contrast CPT 72192 • Imaging | $62 | $97 | $131 |
| CT pelvis with contrast CPT 72193 • Imaging | $171 | $198 | $224 |
| X-ray shoulder complete CPT 73030 • Imaging | $7 | $21 | $34 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $200 | $225 | $250 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $19 | $27 |
| X-ray ankle complete CPT 73610 • Imaging | $12 | $28 | $40 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $157 | $157 | $157 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $90 | $188 |
| CT abdomen without contrast CPT 74150 • Imaging | $56 | $113 | $171 |
| CT abdomen with contrast CPT 74160 • Imaging | $169 | $169 | $169 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $145 | $191 | $257 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $111 | $171 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $155 | $213 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $94 | $145 | $171 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $38 | $101 | $165 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $69 | $74 | $80 |
| Ultrasound transvaginal CPT 76830 • Imaging | $114 | $132 | $149 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $32 | $36 | $40 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $86 | $96 | $120 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $109 | $126 | $152 |
| Screening mammography bilateral CPT 77067 • Imaging | $36 | $70 | $95 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $9 | $19 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $74 | $181 | $300 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $6 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $7 | $9 |
| Lipid panel CPT 80061 • Laboratory | $4 | $7 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $6 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |