| CT head without then with contrast CPT 70470 • Imaging | $210 | $210 | $210 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $172 | $172 | $172 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $211 | $211 | $211 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $203 | $203 | $203 |
| CT angiography neck CPT 70498 • Imaging | $80 | $80 | $80 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $98 | $600 | $1,101 |
| MRI brain without contrast CPT 70551 • Imaging | $377 | $412 | $448 |
| MRI brain with contrast CPT 70552 • Imaging | $415 | $476 | $537 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $131 | $333 | $535 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $10 | $11 |
| Chest X-ray 2 views CPT 71046 • Imaging | $22 | $27 | $34 |
| CT chest without contrast CPT 71250 • Imaging | $53 | $145 | $236 |
| CT chest with contrast CPT 71260 • Imaging | $57 | $170 | $283 |
| CT chest without then with contrast CPT 71270 • Imaging | $331 | $331 | $331 |
| CT angiography chest CPT 71275 • Imaging | $107 | $230 | $352 |
| CT cervical spine without contrast CPT 72125 • Imaging | $225 | $225 | $225 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $224 | $224 | $224 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $224 | $224 | $224 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $332 | $434 | $537 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $73 | $285 | $497 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $407 | $493 | $579 |
| 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 | $24 | $28 | $33 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $75 | $247 | $419 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $10 | $23 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $19 | $22 | $24 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $61 | $68 | $75 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $365 | $441 | $517 |
| CT abdomen without contrast CPT 74150 • Imaging | $54 | $140 | $226 |
| CT abdomen with contrast CPT 74160 • Imaging | $287 | $287 | $287 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $313 | $313 | $313 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $124 | $187 | $250 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $85 | $95 | $105 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $116 | $261 | $406 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $37 | $41 | $45 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $112 | $116 | $120 |
| Ultrasound transvaginal CPT 76830 • Imaging | $31 | $92 | $149 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $38 | $71 | $104 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $36 | $69 | $102 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $45 | $88 | $131 |
| Screening mammography bilateral CPT 77067 • Imaging | $34 | $71 | $108 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $84 | $84 | $84 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $89 | $170 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $6 | $7 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $5 |