| CT head without then with contrast CPT 70470 • Imaging | $194 | $194 | $194 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $44 | $44 | $44 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $58 | $58 | $58 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $135 | $231 | $327 |
| CT angiography neck CPT 70498 • Imaging | $209 | $209 | $209 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $293 | $447 | $601 |
| MRI brain without contrast CPT 70551 • Imaging | $154 | $251 | $348 |
| MRI brain with contrast CPT 70552 • Imaging | $228 | $228 | $228 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $117 | $153 | $189 |
| Chest X-ray single view CPT 71045 • Imaging | $15 | $26 | $45 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $17 | $20 |
| CT chest without contrast CPT 71250 • Imaging | $60 | $177 | $236 |
| CT chest with contrast CPT 71260 • Imaging | $100 | $150 | $199 |
| CT chest without then with contrast CPT 71270 • Imaging | $236 | $293 | $349 |
| CT angiography chest CPT 71275 • Imaging | $213 | $213 | $213 |
| CT cervical spine without contrast CPT 72125 • Imaging | $55 | $55 | $55 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $183 | $183 | $183 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $131 | $131 | $131 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $148 | $276 | $340 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $76 | $164 | $251 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $225 | $225 | $225 |
| CT pelvis without contrast CPT 72192 • Imaging | $92 | $92 | $92 |
| CT pelvis with contrast CPT 72193 • Imaging | $195 | $216 | $238 |
| X-ray shoulder complete CPT 73030 • Imaging | $29 | $46 | $64 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $70 | $70 | $70 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $8 | $8 |
| X-ray ankle complete CPT 73610 • Imaging | $5 | $34 | $66 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $69 | $233 | $397 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $237 | $301 | $365 |
| CT abdomen without contrast CPT 74150 • Imaging | $61 | $61 | $61 |
| CT abdomen with contrast CPT 74160 • Imaging | $177 | $177 | $177 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $203 | $203 | $203 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $204 | $290 | $377 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $94 | $421 | $633 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $163 | $343 | $603 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $130 | $130 | $130 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $120 | $120 | $120 |
| Ultrasound transvaginal CPT 76830 • Imaging | $130 | $130 | $130 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $21 | $50 | $80 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $79 | $145 | $221 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $172 | $242 | $313 |
| Screening mammography bilateral CPT 77067 • Imaging | $60 | $141 | $225 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $31 | $31 | $31 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $245 | $368 | $490 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $5 | $6 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $5 | $5 |
| Lipid panel CPT 80061 • Laboratory | $6 | $15 | $24 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $4 | $4 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |