| MRI brain without contrast CPT 70551 • Imaging | $69 | $69 | $69 |
| MRI brain with contrast CPT 70552 • Imaging | $64 | $64 | $64 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $108 | $108 | $108 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $7 | $7 |
| Chest X-ray 2 views CPT 71046 • Imaging | $10 | $10 | $10 |
| CT chest without contrast CPT 71250 • Imaging | $39 | $39 | $39 |
| CT chest with contrast CPT 71260 • Imaging | $55 | $55 | $55 |
| CT angiography chest CPT 71275 • Imaging | $66 | $66 | $66 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $70 | $70 | $70 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $91 | $91 | $91 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $70 | $70 | $70 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $9 | $9 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $64 | $64 | $64 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $6 | $6 | $6 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $8 | $8 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $49 | $49 | $49 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $64 | $64 | $64 |
| CT abdomen without contrast CPT 74150 • Imaging | $42 | $42 | $42 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $63 | $63 | $63 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $66 | $66 | $66 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $94 | $94 | $94 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $39 | $39 | $39 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $27 | $27 | $27 |
| Ultrasound transvaginal CPT 76830 • Imaging | $25 | $25 | $25 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $25 | $25 | $25 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $38 | $38 | $38 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $36 | $36 | $36 |
| Screening mammography bilateral CPT 77067 • Imaging | $95 | $95 | $95 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $58 | $58 | $58 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $5 | $5 | $5 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $2 | $2 | $2 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $7 | $7 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $4 | $4 | $4 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $4 | $4 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $1 | $1 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $96 | $96 | $96 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $8 | $8 | $8 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $8 | $8 | $8 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $3 | $3 | $3 |
| Creatinine urine CPT 82570 • Laboratory | $2 | $2 | $2 |
| Ferritin CPT 82728 • Laboratory | $4 | $4 | $4 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $3 | $3 | $3 |
| Iron serum CPT 83540 • Laboratory | $3 | $3 | $3 |
| Iron binding capacity CPT 83550 • Laboratory | $4 | $4 | $4 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $8 | $8 | $8 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $2 | $2 | $2 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $5 | $5 | $5 |