| MRI brain with contrast CPT 70552 • Imaging | $30 | $30 | $30 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $30 | $30 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $20 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $13 | $17 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $68 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $105 | $168 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $64 | $160 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $33 | $35 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $33 | $35 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $33 | $35 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $30 | $30 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $30 | $30 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $30 | $30 |
| CT pelvis without contrast CPT 72192 • Imaging | $62 | $62 | $62 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $27 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $206 | $206 | $206 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $22 | $27 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $6 | $23 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $64 | $64 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $127 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $85 | $139 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $88 | $145 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $131 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $230 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $350 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $30 | $30 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $69 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $88 | $97 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $93 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $75 | $92 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $127 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $95 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $368 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $3 | $7 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $7 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $1 | $2 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $8 | $18 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Creatinine urine CPT 82570 • Laboratory | $4 | $4 | $4 |
| Ferritin CPT 82728 • Laboratory | $11 | $11 | $11 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $7 | $7 | $7 |