| CT head without then with contrast CPT 70470 • Imaging | $328 | $328 | $328 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $95 | $138 | $190 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $63 | $63 | $63 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $188 | $241 | $293 |
| CT angiography neck CPT 70498 • Imaging | $62 | $133 | $252 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $348 | $689 | $863 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $185 | $445 |
| MRI brain with contrast CPT 70552 • Imaging | $513 | $516 | $518 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $113 | $474 | $983 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $15 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $12 | $19 | $32 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $168 | $279 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $144 | $330 |
| CT chest without then with contrast CPT 71270 • Imaging | $200 | $301 | $402 |
| CT angiography chest CPT 71275 • Imaging | $64 | $200 | $443 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $74 | $132 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $148 | $277 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $148 | $277 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $78 | $258 | $500 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $195 | $372 | $463 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $242 | $458 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $161 | $270 |
| CT pelvis with contrast CPT 72193 • Imaging | $224 | $241 | $257 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $24 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $429 | $431 | $434 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $21 | $28 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $21 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $435 | $437 | $439 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $297 | $497 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $156 | $270 |
| CT abdomen with contrast CPT 74160 • Imaging | $268 | $268 | $268 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $68 | $150 | $236 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $99 | $142 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $212 | $372 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $111 | $309 | $465 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $36 | $78 | $120 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $33 | $81 | $117 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $60 | $86 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $61 | $64 | $67 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $61 | $101 | $140 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $53 | $141 | $255 |
| Screening mammography bilateral CPT 77067 • Imaging | $27 | $59 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $70 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $85 | $231 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $7 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $5 | $7 |
| Lipid panel CPT 80061 • Laboratory | $4 | $7 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $5 |