| CT head without then with contrast CPT 70470 • Imaging | $403 | $403 | $403 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $73 | $95 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $353 | $353 | $353 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $91 | $152 |
| CT angiography neck CPT 70498 • Imaging | $30 | $239 | $624 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $487 | $665 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $359 | $471 |
| MRI brain with contrast CPT 70552 • Imaging | $196 | $404 | $509 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $536 | $770 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $28 | $54 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $43 | $69 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $153 | $271 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $217 | $414 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $260 | $489 |
| CT angiography chest CPT 71275 • Imaging | $64 | $343 | $439 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $131 | $328 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $58 | $110 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $58 | $110 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $356 | $469 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $260 | $469 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $313 | $462 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $85 | $119 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $206 | $382 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $28 | $34 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $382 | $441 | $484 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $18 | $28 | $32 |
| X-ray ankle complete CPT 73610 • Imaging | $22 | $36 | $73 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $394 | $436 | $457 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $248 | $457 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $190 | $273 |
| CT abdomen with contrast CPT 74160 • Imaging | $520 | $520 | $520 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $203 | $433 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $243 | $424 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $356 | $689 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $351 | $453 | $554 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $77 | $112 | $138 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $125 | $254 |
| Ultrasound transvaginal CPT 76830 • Imaging | $88 | $151 | $286 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $115 | $168 | $275 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $183 | $348 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $194 | $272 |
| Screening mammography bilateral CPT 77067 • Imaging | $95 | $104 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $56 | $83 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $570 | $999 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $5 | $11 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $7 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $8 | $8 |
| Lipid panel CPT 80061 • Laboratory | $3 | $9 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |