| CT head without then with contrast CPT 70470 • Imaging | $181 | $181 | $181 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $54 | $54 | $54 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $221 | $221 | $221 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $276 | $276 | $276 |
| CT angiography neck CPT 70498 • Imaging | $538 | $538 | $538 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $515 | $808 | $1,101 |
| MRI brain without contrast CPT 70551 • Imaging | $448 | $450 | $453 |
| MRI brain with contrast CPT 70552 • Imaging | $421 | $479 | $537 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $111 | $121 | $131 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $10 | $11 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $25 | $34 |
| CT chest without contrast CPT 71250 • Imaging | $49 | $142 | $236 |
| CT chest with contrast CPT 71260 • Imaging | $274 | $278 | $283 |
| CT chest without then with contrast CPT 71270 • Imaging | $65 | $65 | $65 |
| CT angiography chest CPT 71275 • Imaging | $107 | $262 | $418 |
| CT cervical spine without contrast CPT 72125 • Imaging | $174 | $174 | $174 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $48 | $48 | $48 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $48 | $48 | $48 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $406 | $471 | $537 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $333 | $415 | $497 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $333 | $456 | $579 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $51 | $51 |
| CT pelvis with contrast CPT 72193 • Imaging | $259 | $259 | $259 |
| X-ray shoulder complete CPT 73030 • Imaging | $20 | $27 | $33 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $75 | $217 | $360 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $9 | $10 |
| X-ray ankle complete CPT 73610 • Imaging | $21 | $22 | $24 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $75 | $257 | $440 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $65 | $291 | $517 |
| CT abdomen without contrast CPT 74150 • Imaging | $218 | $222 | $226 |
| CT abdomen with contrast CPT 74160 • Imaging | $60 | $60 | $60 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $66 | $66 | $66 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $132 | $191 | $250 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $105 | $178 | $251 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $94 | $105 | $116 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $38 | $42 | $45 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $93 | $106 | $120 |
| Ultrasound transvaginal CPT 76830 • Imaging | $38 | $63 | $88 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $32 | $35 | $38 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $102 | $111 | $120 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $131 | $142 | $152 |
| Screening mammography bilateral CPT 77067 • Imaging | $108 | $115 | $123 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $89 | $279 | $470 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $5 | $6 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $5 |