| CT head without then with contrast CPT 70470 • Imaging | $216 | $216 | $216 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $41 | $41 | $41 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $53 | $53 | $53 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $41 | $41 | $41 |
| CT angiography neck CPT 70498 • Imaging | $41 | $41 | $41 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $41 | $213 | $503 |
| MRI brain without contrast CPT 70551 • Imaging | $95 | $272 | $475 |
| MRI brain with contrast CPT 70552 • Imaging | $41 | $283 | $475 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $41 | $176 | $393 |
| Chest X-ray single view CPT 71045 • Imaging | $17 | $18 | $20 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $12 | $19 |
| CT chest without contrast CPT 71250 • Imaging | $41 | $45 | $53 |
| CT chest with contrast CPT 71260 • Imaging | $54 | $146 | $239 |
| CT chest without then with contrast CPT 71270 • Imaging | $57 | $57 | $57 |
| CT angiography chest CPT 71275 • Imaging | $79 | $184 | $374 |
| CT cervical spine without contrast CPT 72125 • Imaging | $42 | $42 | $42 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $41 | $41 | $41 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $106 | $106 | $106 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $77 | $296 | $475 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $41 | $119 | $238 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $166 | $293 | $475 |
| CT pelvis without contrast CPT 72192 • Imaging | $45 | $45 | $45 |
| CT pelvis with contrast CPT 72193 • Imaging | $48 | $48 | $48 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $29 | $41 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $41 | $257 | $475 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $26 | $33 | $41 |
| X-ray ankle complete CPT 73610 • Imaging | $6 | $19 | $41 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $41 | $167 | $365 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $183 | $378 | $475 |
| CT abdomen without contrast CPT 74150 • Imaging | $43 | $137 | $213 |
| CT abdomen with contrast CPT 74160 • Imaging | $41 | $41 | $41 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $292 | $292 | $292 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $69 | $115 | $184 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $95 | $202 | $292 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $272 | $337 | $371 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $58 | $105 | $141 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $23 | $90 | $133 |
| Ultrasound transvaginal CPT 76830 • Imaging | $41 | $92 | $126 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $36 | $39 | $41 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $33 | $69 | $93 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $107 | $141 | $169 |
| Screening mammography bilateral CPT 77067 • Imaging | $31 | $83 | $119 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $9 | $9 | $9 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $64 | $202 | $478 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $9 | $10 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $5 | $7 |
| Lipid panel CPT 80061 • Laboratory | $8 | $9 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $7 | $9 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |