| CT maxillofacial without contrast CPT 70486 • Imaging | $224 | $224 | $224 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $270 | $270 | $270 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $203 | $203 | $203 |
| CT angiography neck CPT 70498 • Imaging | $558 | $558 | $558 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $647 | $755 | $863 |
| MRI brain without contrast CPT 70551 • Imaging | $67 | $256 | $445 |
| MRI brain with contrast CPT 70552 • Imaging | $497 | $507 | $518 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $642 | $813 | $983 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $10 | $11 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $25 | $32 |
| CT chest without contrast CPT 71250 • Imaging | $53 | $166 | $279 |
| CT chest with contrast CPT 71260 • Imaging | $57 | $193 | $330 |
| CT chest without then with contrast CPT 71270 • Imaging | $268 | $268 | $268 |
| CT angiography chest CPT 71275 • Imaging | $93 | $267 | $440 |
| CT cervical spine without contrast CPT 72125 • Imaging | $225 | $225 | $225 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $171 | $171 | $171 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $171 | $171 | $171 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $78 | $205 | $332 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $413 | $438 | $463 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $206 | $340 |
| CT pelvis without contrast CPT 72192 • Imaging | $162 | $162 | $162 |
| CT pelvis with contrast CPT 72193 • Imaging | $202 | $202 | $202 |
| X-ray shoulder complete CPT 73030 • Imaging | $17 | $19 | $21 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $62 | $248 | $434 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $17 | $25 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $14 | $19 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $374 | $407 | $439 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $365 | $401 | $436 |
| CT abdomen without contrast CPT 74150 • Imaging | $215 | $243 | $270 |
| CT abdomen with contrast CPT 74160 • Imaging | $229 | $229 | $229 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $377 | $377 | $377 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $142 | $173 | $205 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $236 | $304 | $372 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $111 | $258 | $406 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $81 | $101 | $120 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $112 | $114 | $117 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $53 | $73 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $67 | $70 | $73 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $121 | $130 | $140 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $53 | $81 | $108 |
| Screening mammography bilateral CPT 77067 • Imaging | $34 | $37 | $40 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $84 | $84 | $84 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $71 | $78 | $85 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $7 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $9 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $5 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $5 |