| CT head without then with contrast CPT 70470 • Imaging | $170 | $170 | $170 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $109 | $204 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $73 | $73 | $73 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $173 | $303 |
| CT angiography neck CPT 70498 • Imaging | $30 | $68 | $112 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $257 | $485 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $111 | $199 |
| MRI brain with contrast CPT 70552 • Imaging | $115 | $115 | $115 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $278 | $486 |
| Chest X-ray single view CPT 71045 • Imaging | $11 | $17 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $14 | $26 | $38 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $57 | $67 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $61 | $80 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $193 | $356 |
| CT angiography chest CPT 71275 • Imaging | $64 | $347 | $629 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $102 | $241 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $101 | $236 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $43 | $64 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $107 | $195 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $117 | $205 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $89 | $195 | $301 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $84 | $118 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $123 | $215 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $30 | $37 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $106 | $166 | $226 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $12 | $23 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $35 | $42 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $75 | $151 | $226 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $126 | $226 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $95 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $82 | $82 | $82 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $172 | $342 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $118 | $158 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $283 | $301 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $344 | $387 | $466 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $84 | $87 | $90 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $72 | $133 |
| Ultrasound transvaginal CPT 76830 • Imaging | $36 | $62 | $88 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $41 | $60 | $79 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $108 | $123 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $160 | $192 | $225 |
| Screening mammography bilateral CPT 77067 • Imaging | $51 | $77 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $33 | $38 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $58 | $347 | $592 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $5 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $4 | $6 |
| Lipid panel CPT 80061 • Laboratory | $4 | $8 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |