| CT head without then with contrast CPT 70470 • Imaging | $73 | $73 | $73 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $40 | $49 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $65 | $65 | $65 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $87 | $144 |
| CT angiography neck CPT 70498 • Imaging | $30 | $178 | $326 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $420 | $896 |
| MRI brain without contrast CPT 70551 • Imaging | $246 | $418 | $475 |
| MRI brain with contrast CPT 70552 • Imaging | $102 | $102 | $102 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $262 | $475 |
| Chest X-ray single view CPT 71045 • Imaging | $18 | $37 | $54 |
| Chest X-ray 2 views CPT 71046 • Imaging | $23 | $55 | $70 |
| CT chest without contrast CPT 71250 • Imaging | $46 | $141 | $248 |
| CT chest with contrast CPT 71260 • Imaging | $107 | $213 | $316 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $143 | $256 |
| CT angiography chest CPT 71275 • Imaging | $41 | $62 | $104 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $44 | $57 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $101 | $172 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $100 | $171 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $85 | $378 | $475 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $306 | $632 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $85 | $283 | $475 |
| CT pelvis without contrast CPT 72192 • Imaging | $98 | $98 | $98 |
| CT pelvis with contrast CPT 72193 • Imaging | $41 | $54 | $66 |
| X-ray shoulder complete CPT 73030 • Imaging | $25 | $34 | $41 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $174 | $307 | $436 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $30 | $37 | $41 |
| X-ray ankle complete CPT 73610 • Imaging | $38 | $40 | $41 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $206 | $525 | $896 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $124 | $321 | $475 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $98 | $165 |
| CT abdomen with contrast CPT 74160 • Imaging | $73 | $73 | $73 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $128 | $226 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $130 | $214 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $255 | $320 | $342 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $351 | $598 | $819 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $100 | $112 | $136 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $89 | $125 |
| Ultrasound transvaginal CPT 76830 • Imaging | $41 | $73 | $136 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $39 | $40 | $41 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $47 | $162 | $246 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $129 | $129 | $129 |
| Screening mammography bilateral CPT 77067 • Imaging | $64 | $115 | $151 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $32 | $32 | $32 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $667 | $923 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $7 | $17 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $10 | $16 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $12 | $20 |
| Lipid panel CPT 80061 • Laboratory | $6 | $17 | $25 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $7 | $10 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $4 | $6 |