| CT maxillofacial without contrast CPT 70486 • Imaging | $77 | $77 | $77 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $88 | $88 | $88 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $107 | $107 | $107 |
| CT angiography neck CPT 70498 • Imaging | $74 | $74 | $74 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $317 | $317 | $317 |
| MRI brain without contrast CPT 70551 • Imaging | $182 | $182 | $182 |
| MRI brain with contrast CPT 70552 • Imaging | $176 | $176 | $176 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $200 | $200 | $200 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $8 | $8 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $17 | $17 |
| CT chest without contrast CPT 71250 • Imaging | $49 | $49 | $49 |
| CT chest with contrast CPT 71260 • Imaging | $160 | $160 | $160 |
| CT chest without then with contrast CPT 71270 • Imaging | $58 | $58 | $58 |
| CT angiography chest CPT 71275 • Imaging | $77 | $77 | $77 |
| CT cervical spine without contrast CPT 72125 • Imaging | $42 | $42 | $42 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $127 | $127 | $127 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $84 | $84 | $84 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $177 | $177 | $177 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $114 | $114 | $114 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $63 | $63 | $63 |
| CT pelvis without contrast CPT 72192 • Imaging | $46 | $46 | $46 |
| CT pelvis with contrast CPT 72193 • Imaging | $49 | $49 | $49 |
| X-ray shoulder complete CPT 73030 • Imaging | $27 | $27 | $27 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $58 | $58 | $58 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $7 | $7 | $7 |
| X-ray ankle complete CPT 73610 • Imaging | $28 | $28 | $28 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $209 | $209 | $209 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $186 | $186 | $186 |
| CT abdomen without contrast CPT 74150 • Imaging | $122 | $122 | $122 |
| CT abdomen with contrast CPT 74160 • Imaging | $201 | $201 | $201 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $59 | $59 | $59 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $90 | $90 | $90 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $189 | $189 | $189 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $214 | $214 | $214 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $66 | $66 | $66 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $31 | $31 | $31 |
| Ultrasound transvaginal CPT 76830 • Imaging | $71 | $71 | $71 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $29 | $29 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $75 | $75 | $75 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $95 | $95 | $95 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $32 | $32 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $8 | $8 | $8 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $319 | $319 | $319 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $8 | $8 | $8 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |