| CT maxillofacial without contrast CPT 70486 • Imaging | $42 | $42 | $42 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $197 | $197 | $197 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $149 | $149 | $149 |
| CT angiography neck CPT 70498 • Imaging | $344 | $344 | $344 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $78 | $78 | $78 |
| MRI brain without contrast CPT 70551 • Imaging | $296 | $296 | $296 |
| MRI brain with contrast CPT 70552 • Imaging | $354 | $354 | $354 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $743 | $743 | $743 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $8 | $8 |
| Chest X-ray 2 views CPT 71046 • Imaging | $22 | $22 | $22 |
| CT chest without contrast CPT 71250 • Imaging | $156 | $156 | $156 |
| CT chest with contrast CPT 71260 • Imaging | $232 | $232 | $232 |
| CT chest without then with contrast CPT 71270 • Imaging | $284 | $284 | $284 |
| CT angiography chest CPT 71275 • Imaging | $70 | $70 | $70 |
| CT cervical spine without contrast CPT 72125 • Imaging | $42 | $42 | $42 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $42 | $42 | $42 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $156 | $156 | $156 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $354 | $354 | $354 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $328 | $328 | $328 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $328 | $328 | $328 |
| CT pelvis without contrast CPT 72192 • Imaging | $196 | $196 | $196 |
| CT pelvis with contrast CPT 72193 • Imaging | $223 | $223 | $223 |
| X-ray shoulder complete CPT 73030 • Imaging | $22 | $22 | $22 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $293 | $293 | $293 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $20 | $20 |
| X-ray ankle complete CPT 73610 • Imaging | $14 | $14 | $14 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $342 | $342 | $342 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $49 | $49 | $49 |
| CT abdomen without contrast CPT 74150 • Imaging | $43 | $43 | $43 |
| CT abdomen with contrast CPT 74160 • Imaging | $46 | $46 | $46 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $275 | $275 | $275 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $65 | $65 | $65 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $191 | $191 | $191 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $253 | $253 | $253 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $52 | $52 | $52 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $79 | $79 | $79 |
| Ultrasound transvaginal CPT 76830 • Imaging | $66 | $66 | $66 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $25 | $25 | $25 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $98 | $98 | $98 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $36 | $36 | $36 |
| Screening mammography bilateral CPT 77067 • Imaging | $100 | $100 | $100 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $74 | $74 | $74 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $100 | $100 | $100 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $6 | $6 | $6 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $3 | $3 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $7 | $7 | $7 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $3 | $3 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |