| CT head without then with contrast CPT 70470 • Imaging | $130 | $130 | $130 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $56 | $56 | $56 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $238 | $238 | $238 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $169 | $201 | $233 |
| CT angiography neck CPT 70498 • Imaging | $439 | $439 | $439 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $299 | $389 | $479 |
| MRI brain without contrast CPT 70551 • Imaging | $85 | $223 | $425 |
| MRI brain with contrast CPT 70552 • Imaging | $228 | $326 | $425 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $113 | $113 | $113 |
| Chest X-ray single view CPT 71045 • Imaging | $19 | $22 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $20 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $122 | $142 | $182 |
| CT chest with contrast CPT 71260 • Imaging | $166 | $166 | $166 |
| CT chest without then with contrast CPT 71270 • Imaging | $181 | $193 | $206 |
| CT angiography chest CPT 71275 • Imaging | $233 | $294 | $354 |
| CT cervical spine without contrast CPT 72125 • Imaging | $186 | $186 | $186 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $182 | $182 | $182 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $181 | $181 | $181 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $74 | $195 | $425 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $74 | $74 | $74 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $74 | $249 | $425 |
| CT pelvis without contrast CPT 72192 • Imaging | $90 | $90 | $90 |
| CT pelvis with contrast CPT 72193 • Imaging | $166 | $186 | $206 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $31 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $174 | $299 | $425 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $20 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $22 | $33 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $281 | $353 | $425 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $68 | $76 | $85 |
| CT abdomen without contrast CPT 74150 • Imaging | $59 | $92 | $124 |
| CT abdomen with contrast CPT 74160 • Imaging | $63 | $63 | $63 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $194 | $194 | $194 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $86 | $127 | $167 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $90 | $218 | $282 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $243 | $315 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $119 | $134 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $90 | $93 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $34 | $70 | $106 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $106 | $118 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $87 | $111 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $140 | $150 | $161 |
| Screening mammography bilateral CPT 77067 • Imaging | $93 | $107 | $114 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $36 | $36 | $36 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $377 | $383 | $389 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $10 | $14 |
| Lipid panel CPT 80061 • Laboratory | $9 | $12 | $18 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |