| CT maxillofacial without contrast CPT 70486 • Imaging | $133 | $133 | $133 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $160 | $160 | $160 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $155 | $155 | $155 |
| CT angiography neck CPT 70498 • Imaging | $278 | $278 | $278 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $76 | $271 | $465 |
| MRI brain without contrast CPT 70551 • Imaging | $52 | $136 | $219 |
| MRI brain with contrast CPT 70552 • Imaging | $63 | $139 | $215 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $81 | $97 | $114 |
| Chest X-ray single view CPT 71045 • Imaging | $6 | $8 | $10 |
| Chest X-ray 2 views CPT 71046 • Imaging | $8 | $9 | $11 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $79 | $120 |
| CT chest with contrast CPT 71260 • Imaging | $120 | $138 | $155 |
| CT chest without then with contrast CPT 71270 • Imaging | $69 | $69 | $69 |
| CT angiography chest CPT 71275 • Imaging | $64 | $174 | $285 |
| CT cervical spine without contrast CPT 72125 • Imaging | $122 | $122 | $122 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $121 | $121 | $121 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $120 | $120 | $120 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $53 | $63 | $74 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $53 | $63 | $74 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $52 | $95 | $138 |
| CT pelvis without contrast CPT 72192 • Imaging | $139 | $139 | $139 |
| CT pelvis with contrast CPT 72193 • Imaging | $156 | $156 | $156 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $26 | $43 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $49 | $136 | $224 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $6 | $7 | $8 |
| X-ray ankle complete CPT 73610 • Imaging | $20 | $21 | $21 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $47 | $196 | $344 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $136 | $224 |
| CT abdomen without contrast CPT 74150 • Imaging | $42 | $51 | $59 |
| CT abdomen with contrast CPT 74160 • Imaging | $219 | $219 | $219 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $70 | $70 | $70 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $61 | $74 | $87 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $180 | $295 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $72 | $203 | $335 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $40 | $62 | $84 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $72 | $74 | $76 |
| Ultrasound transvaginal CPT 76830 • Imaging | $83 | $100 | $117 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $56 | $77 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $29 | $78 | $127 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $36 | $74 | $113 |
| Screening mammography bilateral CPT 77067 • Imaging | $37 | $64 | $91 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $70 | $74 | $78 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $6 | $12 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $5 | $6 |
| Lipid panel CPT 80061 • Laboratory | $6 | $7 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $4 | $5 |