| CT head without then with contrast CPT 70470 • Imaging | $54 | $54 | $54 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $41 | $72 | $89 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $94 | $133 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $163 | $308 |
| CT angiography neck CPT 70498 • Imaging | $76 | $137 | $252 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $103 | $270 | $475 |
| MRI brain without contrast CPT 70551 • Imaging | $128 | $301 | $475 |
| MRI brain with contrast CPT 70552 • Imaging | $106 | $254 | $402 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $214 | $313 | $402 |
| Chest X-ray single view CPT 71045 • Imaging | $5 | $18 | $39 |
| Chest X-ray 2 views CPT 71046 • Imaging | $6 | $15 | $32 |
| CT chest without contrast CPT 71250 • Imaging | $52 | $145 | $221 |
| CT chest with contrast CPT 71260 • Imaging | $38 | $57 | $78 |
| CT chest without then with contrast CPT 71270 • Imaging | $59 | $250 | $442 |
| CT angiography chest CPT 71275 • Imaging | $144 | $185 | $241 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $73 | $124 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $49 | $116 | $184 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $83 | $102 | $133 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $63 | $224 | $402 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $71 | $126 | $180 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $89 | $227 | $402 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $62 | $71 |
| CT pelvis with contrast CPT 72193 • Imaging | $38 | $47 | $55 |
| X-ray shoulder complete CPT 73030 • Imaging | $8 | $25 | $52 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $224 | $475 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $7 | $19 | $52 |
| X-ray ankle complete CPT 73610 • Imaging | $25 | $28 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $230 | $402 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $138 | $195 | $238 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $127 | $219 |
| CT abdomen with contrast CPT 74160 • Imaging | $118 | $118 | $118 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $169 | $224 | $263 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $159 | $304 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $322 | $510 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $60 | $325 | $572 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $34 | $102 | $188 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $80 | $96 | $117 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $107 | $191 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $33 | $73 | $116 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $108 | $135 | $159 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $95 | $167 | $250 |
| Screening mammography bilateral CPT 77067 • Imaging | $23 | $86 | $128 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $23 | $32 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $75 | $234 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $8 | $14 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $5 | $5 |
| Lipid panel CPT 80061 • Laboratory | $5 | $11 | $21 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $10 | $13 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $3 | $5 |