| CT head without then with contrast CPT 70470 • Imaging | $265 | $265 | $265 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $41 | $53 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $58 | $61 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $112 | $240 |
| CT angiography neck CPT 70498 • Imaging | $30 | $229 | $574 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $252 | $775 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $209 | $525 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $396 | $516 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $255 | $773 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $16 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $15 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $108 | $218 |
| CT chest with contrast CPT 71260 • Imaging | $55 | $147 | $324 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $182 | $335 |
| CT angiography chest CPT 71275 • Imaging | $87 | $255 | $422 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $44 | $54 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $44 | $54 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $72 | $133 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $198 | $495 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $167 | $444 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $215 | $444 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $157 | $261 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $113 | $254 |
| X-ray shoulder complete CPT 73030 • Imaging | $20 | $26 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $235 | $499 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $27 | $30 | $33 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $22 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $288 | $512 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $66 | $238 | $442 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $91 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $336 | $336 | $336 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $176 | $430 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $165 | $228 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $88 | $267 | $356 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $312 | $450 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $38 | $75 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $26 | $68 | $118 |
| Ultrasound transvaginal CPT 76830 • Imaging | $32 | $57 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $56 | $106 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $41 | $88 | $126 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $49 | $119 | $170 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $102 | $137 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $25 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $319 | $426 | $605 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $4 | $6 |
| Lipid panel CPT 80061 • Laboratory | $6 | $9 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |