| CT head without then with contrast CPT 70470 • Imaging | $241 | $241 | $241 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $42 | $54 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $282 | $282 | $282 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $121 | $211 |
| CT angiography neck CPT 70498 • Imaging | $30 | $243 | $456 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $192 | $515 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $206 | $383 |
| MRI brain with contrast CPT 70552 • Imaging | $30 | $189 | $506 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $148 | $504 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $22 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $87 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $55 | $94 | $168 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $150 | $270 |
| CT angiography chest CPT 71275 • Imaging | $255 | $279 | $327 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $102 | $174 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $102 | $173 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $39 | $48 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $124 | $406 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $129 | $333 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $106 | $333 |
| CT pelvis without contrast CPT 72192 • Imaging | $162 | $162 | $162 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $117 | $204 |
| X-ray shoulder complete CPT 73030 • Imaging | $29 | $30 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $141 | $257 | $425 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $21 | $27 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $31 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $30 | $157 | $376 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $203 | $369 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $117 | $161 |
| CT abdomen with contrast CPT 74160 • Imaging | $296 | $296 | $296 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $211 | $392 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $132 | $167 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $319 | $335 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $369 | $425 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $65 | $135 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $87 | $128 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $110 | $121 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $52 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $75 | $95 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $143 | $152 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $73 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $43 | $43 | $43 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $330 | $470 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $9 | $10 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |