| CT head without then with contrast CPT 70470 • Imaging | $63 | $63 | $63 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $95 | $116 | $137 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $109 | $109 | $109 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $49 | $69 |
| CT angiography neck CPT 70498 • Imaging | $62 | $177 | $292 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $94 | $183 | $348 |
| MRI brain without contrast CPT 70551 • Imaging | $30 | $114 | $220 |
| MRI brain with contrast CPT 70552 • Imaging | $89 | $200 | $276 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $85 | $246 | $326 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $18 | $25 |
| Chest X-ray 2 views CPT 71046 • Imaging | $8 | $16 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $64 | $156 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $97 | $193 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $95 | $160 |
| CT angiography chest CPT 71275 • Imaging | $64 | $190 | $299 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $69 | $104 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $69 | $104 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $69 | $103 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $138 | $214 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $91 | $195 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $56 | $165 | $214 |
| CT pelvis without contrast CPT 72192 • Imaging | $54 | $58 | $62 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $105 | $181 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $24 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $51 | $87 | $141 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $19 | $23 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $21 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $50 | $102 | $229 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $69 | $141 |
| CT abdomen without contrast CPT 74150 • Imaging | $44 | $67 | $82 |
| CT abdomen with contrast CPT 74160 • Imaging | $180 | $180 | $180 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $145 | $210 | $275 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $108 | $197 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $234 | $322 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $74 | $297 | $362 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $69 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $32 | $70 | $112 |
| Ultrasound transvaginal CPT 76830 • Imaging | $75 | $89 | $121 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $31 | $73 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $75 | $102 | $132 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $50 | $94 | $115 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $81 | $135 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $314 | $470 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $4 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $5 | $8 |
| Lipid panel CPT 80061 • Laboratory | $3 | $6 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $2 |