| CT head without then with contrast CPT 70470 • Imaging | $63 | $63 | $63 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $84 | $131 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $79 | $104 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $84 | $155 |
| CT angiography neck CPT 70498 • Imaging | $30 | $102 | $192 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $398 | $1,101 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $67 | $82 |
| MRI brain with contrast CPT 70552 • Imaging | $215 | $376 | $537 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $110 | $454 | $994 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $24 | $40 |
| Chest X-ray 2 views CPT 71046 • Imaging | $18 | $24 | $34 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $122 | $301 |
| CT chest with contrast CPT 71260 • Imaging | $56 | $208 | $352 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $145 | $261 |
| CT angiography chest CPT 71275 • Imaging | $144 | $341 | $595 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $39 | $53 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $38 | $50 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $38 | $50 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $113 | $195 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $206 | $586 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $191 | $335 | $579 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $96 | $139 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $48 | $58 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $27 | $48 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $66 | $217 | $517 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $10 | $28 | $52 |
| X-ray ankle complete CPT 73610 • Imaging | $26 | $35 | $53 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $139 | $277 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $157 | $253 | $442 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $110 | $292 |
| CT abdomen with contrast CPT 74160 • Imaging | $63 | $63 | $63 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $92 | $179 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $99 | $150 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $205 | $257 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $260 | $493 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $77 | $91 | $116 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $94 | $182 |
| Ultrasound transvaginal CPT 76830 • Imaging | $34 | $54 | $88 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $71 | $93 | $107 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $85 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $113 | $138 | $186 |
| Screening mammography bilateral CPT 77067 • Imaging | $93 | $110 | $126 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $390 | $462 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $10 | $16 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $11 | $25 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $9 | $15 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |