| CT angiography chest CPT 71275 • Imaging | $93 | $93 | $93 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $78 | $78 | $78 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $463 | $463 | $463 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $72 | $72 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $21 | $21 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $434 | $434 | $434 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $22 | $35 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $8 | $8 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $439 | $439 | $439 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $436 | $436 | $436 |
| CT abdomen without contrast CPT 74150 • Imaging | $270 | $270 | $270 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $142 | $142 | $142 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $372 | $372 | $372 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $111 | $111 | $111 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $120 | $120 | $120 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $117 | $117 | $117 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $33 | $33 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $67 | $67 | $67 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $140 | $140 | $140 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $53 | $53 | $53 |
| Screening mammography bilateral CPT 77067 • Imaging | $40 | $70 | $99 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $85 | $85 | $85 |
| Venipuncture (routine blood draw) CPT 36415 • Lab | $3 | $3 | $4 |
| Urinalysis non-automated without microscopy CPT 81002 • Lab | $1 | $3 | $5 |
| Strep test rapid (Streptococcus group A direct) CPT 87880 • Lab | $7 | $10 | $12 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $6 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $3 | $4 | $5 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $5 | $5 | $5 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $5 | $6 | $7 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $15 | $17 | $19 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Creatinine urine CPT 82570 • Laboratory | $3 | $4 | $5 |
| Ferritin CPT 82728 • Laboratory | $9 | $9 | $9 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $6 | $6 | $6 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $3 | $4 |
| Hemoglobin A1c CPT 83036 • Laboratory | $4 | $5 | $5 |
| Iron serum CPT 83540 • Laboratory | $5 | $5 | $5 |
| Iron binding capacity CPT 83550 • Laboratory | $6 | $6 | $6 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $5 | $7 | $9 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $5 | $5 | $6 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $5 | $7 | $8 |
| Complete blood count with differential CPT 85025 • Laboratory | $4 | $6 | $8 |
| Complete blood count automated CPT 85027 • Laboratory | $2 | $4 | $7 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $5 | $5 | $5 |
| Sedimentation rate (ESR) automated CPT 85652 • Laboratory | $5 | $5 | $5 |
| Partial thromboplastin time (PTT) CPT 85730 • Laboratory | $5 | $5 | $5 |
| Cyclic citrullinated peptide antibody CPT 86200 • Laboratory | $8 | $8 | $8 |