| CT head without then with contrast CPT 70470 • Imaging | $266 | $266 | $266 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $55 | $55 | $55 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $230 | $230 | $230 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $227 | $227 | $227 |
| CT angiography neck CPT 70498 • Imaging | $446 | $446 | $446 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $959 | $993 | $1,026 |
| MRI brain without contrast CPT 70551 • Imaging | $441 | $454 | $468 |
| MRI brain with contrast CPT 70552 • Imaging | $86 | $95 | $104 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $113 | $645 | $1,177 |
| Chest X-ray single view CPT 71045 • Imaging | $11 | $11 | $12 |
| Chest X-ray 2 views CPT 71046 • Imaging | $20 | $28 | $35 |
| CT chest without contrast CPT 71250 • Imaging | $56 | $151 | $247 |
| CT chest with contrast CPT 71260 • Imaging | $267 | $281 | $295 |
| CT chest without then with contrast CPT 71270 • Imaging | $66 | $66 | $66 |
| CT angiography chest CPT 71275 • Imaging | $535 | $578 | $622 |
| CT cervical spine without contrast CPT 72125 • Imaging | $277 | $277 | $277 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $56 | $56 | $56 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $277 | $277 | $277 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $423 | $446 | $468 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $77 | $345 | $612 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $519 | $525 | $530 |
| CT pelvis without contrast CPT 72192 • Imaging | $53 | $53 | $53 |
| CT pelvis with contrast CPT 72193 • Imaging | $257 | $257 | $257 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $10 | $11 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $264 | $462 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $26 | $32 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $15 | $22 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $303 | $541 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $65 | $303 | $541 |
| CT abdomen without contrast CPT 74150 • Imaging | $69 | $140 | $211 |
| CT abdomen with contrast CPT 74160 • Imaging | $61 | $61 | $61 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $68 | $68 | $68 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $105 | $123 | $141 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $99 | $254 | $408 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $122 | $238 | $355 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $36 | $59 | $82 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $43 | $74 | $106 |
| Ultrasound transvaginal CPT 76830 • Imaging | $91 | $97 | $104 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $61 | $82 | $104 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $107 | $123 | $140 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $137 | $158 | $179 |
| Screening mammography bilateral CPT 77067 • Imaging | $157 | $181 | $206 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $11 | $11 | $11 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $93 | $109 | $125 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $5 | $6 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $5 |