| CT head without then with contrast CPT 70470 • Imaging | $130 | $130 | $130 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $56 | $56 | $56 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $173 | $173 | $173 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $165 | $185 | $206 |
| CT angiography neck CPT 70498 • Imaging | $352 | $352 | $352 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $373 | $700 | $1,026 |
| MRI brain without contrast CPT 70551 • Imaging | $73 | $257 | $554 |
| MRI brain with contrast CPT 70552 • Imaging | $228 | $446 | $665 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $110 | $439 | $1,177 |
| Chest X-ray single view CPT 71045 • Imaging | $12 | $25 | $32 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $25 | $41 |
| CT chest without contrast CPT 71250 • Imaging | $148 | $188 | $314 |
| CT chest with contrast CPT 71260 • Imaging | $62 | $113 | $187 |
| CT chest without then with contrast CPT 71270 • Imaging | $221 | $247 | $274 |
| CT angiography chest CPT 71275 • Imaging | $260 | $368 | $622 |
| CT cervical spine without contrast CPT 72125 • Imaging | $53 | $53 | $53 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $132 | $132 | $132 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $181 | $181 | $181 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $74 | $255 | $561 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $158 | $299 | $612 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $74 | $147 | $215 |
| CT pelvis without contrast CPT 72192 • Imaging | $54 | $54 | $54 |
| CT pelvis with contrast CPT 72193 • Imaging | $223 | $223 | $223 |
| X-ray shoulder complete CPT 73030 • Imaging | $20 | $36 | $42 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $66 | $137 | $231 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $31 | $42 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $30 | $44 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $67 | $258 | $462 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $66 | $135 | $230 |
| CT abdomen without contrast CPT 74150 • Imaging | $69 | $79 | $88 |
| CT abdomen with contrast CPT 74160 • Imaging | $165 | $165 | $165 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $263 | $263 | $263 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $86 | $162 | $203 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $90 | $243 | $339 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $352 | $516 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $82 | $108 | $128 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $80 | $119 |
| Ultrasound transvaginal CPT 76830 • Imaging | $34 | $85 | $133 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $84 | $118 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $127 | $140 | $153 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $113 | $165 | $195 |
| Screening mammography bilateral CPT 77067 • Imaging | $44 | $106 | $143 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $78 | $388 | $496 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $9 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $7 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $9 | $14 |
| Lipid panel CPT 80061 • Laboratory | $9 | $15 | $22 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |