| CT head with contrast CPT 70460 • Imaging | $269 | $269 | $269 |
| CT head without then with contrast CPT 70470 • Imaging | $328 | $328 | $328 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $95 | $142 | $190 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $63 | $63 | $63 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $134 | $203 |
| CT angiography neck CPT 70498 • Imaging | $62 | $296 | $531 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $292 | $574 | $855 |
| MRI brain without contrast CPT 70551 • Imaging | $52 | $216 | $441 |
| MRI brain with contrast CPT 70552 • Imaging | $279 | $396 | $513 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $81 | $381 | $569 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $25 | $44 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $20 | $24 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $127 | $277 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $61 | $97 |
| CT chest without then with contrast CPT 71270 • Imaging | $66 | $141 | $215 |
| CT angiography chest CPT 71275 • Imaging | $64 | $204 | $347 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $156 | $277 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $45 | $56 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $128 | $221 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $52 | $182 | $340 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $69 | $303 | $536 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $52 | $117 | $217 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $134 | $217 |
| CT pelvis with contrast CPT 72193 • Imaging | $245 | $279 | $313 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $19 | $36 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $48 | $216 | $429 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $25 | $36 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $23 | $39 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $271 | $385 | $500 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $205 | $497 |
| CT abdomen without contrast CPT 74150 • Imaging | $42 | $136 | $268 |
| CT abdomen with contrast CPT 74160 • Imaging | $106 | $106 | $106 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $68 | $106 | $145 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $140 | $282 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $220 | $367 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $71 | $251 | $465 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $29 | $90 | $206 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $74 | $85 | $106 |
| Ultrasound transvaginal CPT 76830 • Imaging | $38 | $118 | $206 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $24 | $70 | $124 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $109 | $140 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $83 | $106 | $115 |
| Screening mammography bilateral CPT 77067 • Imaging | $58 | $113 | $192 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $70 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $125 | $355 | $651 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $4 | $6 |
| Lipid panel CPT 80061 • Laboratory | $3 | $8 | $13 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $6 | $8 |