| CT head without then with contrast CPT 70470 • Imaging | $147 | $147 | $147 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $77 | $77 | $77 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $106 | $106 | $106 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $156 | $200 | $243 |
| CT angiography neck CPT 70498 • Imaging | $66 | $66 | $66 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $42 | $108 | $174 |
| MRI brain without contrast CPT 70551 • Imaging | $370 | $513 | $798 |
| MRI brain with contrast CPT 70552 • Imaging | $370 | $637 | $904 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $42 | $172 | $303 |
| Chest X-ray single view CPT 71045 • Imaging | $15 | $16 | $17 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $21 | $28 |
| CT chest without contrast CPT 71250 • Imaging | $42 | $108 | $169 |
| CT chest with contrast CPT 71260 • Imaging | $44 | $44 | $44 |
| CT chest without then with contrast CPT 71270 • Imaging | $167 | $226 | $285 |
| CT angiography chest CPT 71275 • Imaging | $240 | $274 | $309 |
| CT cervical spine without contrast CPT 72125 • Imaging | $38 | $38 | $38 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $94 | $94 | $94 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $38 | $38 | $38 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $370 | $536 | $866 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $777 | $777 | $777 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $183 | $276 | $370 |
| CT pelvis without contrast CPT 72192 • Imaging | $72 | $72 | $72 |
| CT pelvis with contrast CPT 72193 • Imaging | $44 | $139 | $234 |
| X-ray shoulder complete CPT 73030 • Imaging | $22 | $31 | $42 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $42 | $403 | $764 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $23 | $23 | $24 |
| X-ray ankle complete CPT 73610 • Imaging | $31 | $38 | $42 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $42 | $50 | $57 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $58 | $180 | $371 |
| CT abdomen without contrast CPT 74150 • Imaging | $71 | $112 | $153 |
| CT abdomen with contrast CPT 74160 • Imaging | $588 | $588 | $588 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $52 | $52 | $52 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $155 | $180 | $205 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $321 | $422 | $623 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $186 | $305 | $365 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $27 | $61 | $95 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $88 | $148 | $207 |
| Ultrasound transvaginal CPT 76830 • Imaging | $95 | $112 | $129 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $42 | $49 | $56 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $104 | $124 | $163 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $132 | $170 | $208 |
| Screening mammography bilateral CPT 77067 • Imaging | $26 | $80 | $107 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $28 | $28 | $28 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $200 | $411 | $690 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $5 | $5 | $6 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $9 | $17 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $12 | $18 |
| Lipid panel CPT 80061 • Laboratory | $28 | $31 | $33 |
| Hepatic function panel CPT 80076 • Laboratory | $20 | $20 | $20 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $5 | $8 |