| CT head without then with contrast CPT 70470 • Imaging | $266 | $266 | $266 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $105 | $245 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $174 | $293 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $170 | $293 |
| CT angiography neck CPT 70498 • Imaging | $30 | $66 | $84 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $67 | $104 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $206 | $512 |
| MRI brain with contrast CPT 70552 • Imaging | $30 | $58 | $86 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $333 | $860 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $16 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $13 | $20 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $123 | $277 |
| CT chest with contrast CPT 71260 • Imaging | $30 | $140 | $327 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $48 | $66 |
| CT angiography chest CPT 71275 • Imaging | $87 | $262 | $443 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $100 | $221 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $45 | $56 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $128 | $221 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $139 | $423 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $83 | $194 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $148 | $458 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $135 | $217 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $114 | $257 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $26 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $30 | $223 | $429 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $25 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $22 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $65 | $65 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $127 | $208 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $123 | $268 |
| CT abdomen with contrast CPT 74160 • Imaging | $268 | $268 | $268 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $120 | $263 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $136 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $99 | $238 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $288 | $355 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $61 | $116 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $78 | $106 |
| Ultrasound transvaginal CPT 76830 • Imaging | $60 | $95 | $119 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $46 | $76 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $34 | $96 | $201 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $159 | $179 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $97 | $206 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $11 | $26 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $305 | $413 | $565 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $1 | $4 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $6 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $8 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |