| CT soft tissue neck with contrast CPT 70491 • Imaging | $227 | $227 | $227 |
| CT angiography neck CPT 70498 • Imaging | $446 | $446 | $446 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $270 | $1,158 | $2,884 |
| MRI brain without contrast CPT 70551 • Imaging | $71 | $317 | $512 |
| MRI brain with contrast CPT 70552 • Imaging | $303 | $896 | $2,245 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $113 | $487 | $974 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $27 | $47 |
| Chest X-ray 2 views CPT 71046 • Imaging | $20 | $42 | $60 |
| CT chest without contrast CPT 71250 • Imaging | $56 | $158 | $277 |
| CT chest with contrast CPT 71260 • Imaging | $95 | $638 | $1,890 |
| CT chest without then with contrast CPT 71270 • Imaging | $66 | $66 | $66 |
| CT angiography chest CPT 71275 • Imaging | $202 | $408 | $535 |
| CT cervical spine without contrast CPT 72125 • Imaging | $56 | $56 | $56 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $277 | $277 | $277 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $56 | $56 | $56 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $77 | $301 | $455 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $207 | $382 | $536 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $215 | $458 | $752 |
| CT pelvis without contrast CPT 72192 • Imaging | $53 | $53 | $53 |
| CT pelvis with contrast CPT 72193 • Imaging | $313 | $313 | $313 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $46 | $77 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $339 | $482 | $752 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $39 | $60 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $35 | $65 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $317 | $435 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $65 | $368 | $752 |
| CT abdomen without contrast CPT 74150 • Imaging | $85 | $180 | $268 |
| CT abdomen with contrast CPT 74160 • Imaging | $329 | $329 | $329 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $411 | $411 | $411 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $91 | $169 | $329 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $99 | $1,038 | $3,103 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $255 | $420 | $610 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $36 | $114 | $211 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $60 | $142 | $264 |
| Ultrasound transvaginal CPT 76830 • Imaging | $57 | $113 | $173 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $56 | $125 | $256 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $61 | $146 | $226 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $54 | $183 | $285 |
| Screening mammography bilateral CPT 77067 • Imaging | $58 | $158 | $232 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $101 | $101 | $101 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $311 | $591 | $752 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $7 | $12 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $13 | $23 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $14 | $21 |
| Lipid panel CPT 80061 • Laboratory | $9 | $20 | $36 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $13 | $22 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $5 | $6 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $5 | $7 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $3 | $4 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $14 | $23 | $31 |