| CT head without then with contrast CPT 70470 • Imaging | $138 | $138 | $138 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $40 | $49 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $184 | $184 | $184 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $55 | $79 |
| CT angiography neck CPT 70498 • Imaging | $30 | $65 | $100 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $125 | $314 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $172 | $250 |
| MRI brain with contrast CPT 70552 • Imaging | $30 | $101 | $244 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $64 | $131 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $31 | $35 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $118 | $175 |
| CT chest with contrast CPT 71260 • Imaging | $71 | $136 | $168 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $55 | $79 |
| CT angiography chest CPT 71275 • Imaging | $104 | $205 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $86 | $141 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $114 | $198 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $85 | $140 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $195 | $207 | $243 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $113 | $195 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $71 | $177 | $244 |
| CT pelvis without contrast CPT 72192 • Imaging | $161 | $161 | $161 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $143 | $257 |
| X-ray shoulder complete CPT 73030 • Imaging | $11 | $25 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $78 | $163 | $206 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $6 | $25 | $35 |
| X-ray ankle complete CPT 73610 • Imaging | $7 | $26 | $37 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $30 | $127 | $288 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $103 | $193 | $256 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $94 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $73 | $73 | $73 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $67 | $73 | $80 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $197 | $222 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $204 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $115 | $291 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $35 | $46 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $87 | $124 |
| Ultrasound transvaginal CPT 76830 • Imaging | $94 | $101 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $81 | $121 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $119 | $147 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $57 | $112 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $91 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $33 | $33 | $33 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $90 | $299 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $1 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $8 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |