| CT head with contrast CPT 70460 • Imaging | $30 | $30 | $30 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $62 | $95 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $30 | $30 |
| CT angiography neck CPT 70498 • Imaging | $30 | $46 | $62 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $288 | $647 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $170 | $485 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $408 | $582 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $492 | $1,078 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $15 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $22 | $35 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $97 | $224 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $110 | $212 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $64 | $155 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $33 | $35 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $33 | $35 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $33 | $35 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $247 | $485 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $183 | $413 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $206 | $538 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $51 | $51 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $21 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $141 | $280 | $480 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $11 | $22 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $6 | $19 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $61 | $208 | $480 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $187 | $480 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $96 | $215 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $88 | $145 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $128 | $205 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $269 | $321 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $94 | $252 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $81 | $93 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $60 | $86 |
| Ultrasound transvaginal CPT 76830 • Imaging | $31 | $62 | $86 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $31 | $63 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $46 | $86 | $121 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $96 | $119 | $153 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $67 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $263 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $6 | $8 |
| Lipid panel CPT 80061 • Laboratory | $3 | $9 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $3 | $7 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $5 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $18 | $96 |