| CT maxillofacial without contrast CPT 70486 • Imaging | $107 | $107 | $107 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $45 | $45 | $45 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $55 | $55 | $55 |
| CT angiography neck CPT 70498 • Imaging | $156 | $156 | $156 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $85 | $131 | $176 |
| MRI brain without contrast CPT 70551 • Imaging | $174 | $384 | $595 |
| MRI brain with contrast CPT 70552 • Imaging | $71 | $333 | $595 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $284 | $351 | $419 |
| Chest X-ray single view CPT 71045 • Imaging | $12 | $18 | $25 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $16 | $24 |
| CT chest without contrast CPT 71250 • Imaging | $75 | $96 | $116 |
| CT chest with contrast CPT 71260 • Imaging | $42 | $96 | $150 |
| CT chest without then with contrast CPT 71270 • Imaging | $178 | $178 | $178 |
| CT angiography chest CPT 71275 • Imaging | $231 | $308 | $385 |
| CT cervical spine without contrast CPT 72125 • Imaging | $43 | $43 | $43 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $98 | $98 | $98 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $40 | $40 | $40 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $110 | $352 | $595 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $42 | $51 | $59 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $110 | $353 | $595 |
| CT pelvis without contrast CPT 72192 • Imaging | $112 | $112 | $112 |
| CT pelvis with contrast CPT 72193 • Imaging | $46 | $46 | $46 |
| X-ray shoulder complete CPT 73030 • Imaging | $16 | $29 | $42 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $42 | $83 | $124 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $7 | $24 | $42 |
| X-ray ankle complete CPT 73610 • Imaging | $25 | $34 | $42 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $147 | $371 | $595 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $54 | $115 | $176 |
| CT abdomen without contrast CPT 74150 • Imaging | $115 | $250 | $385 |
| CT abdomen with contrast CPT 74160 • Imaging | $182 | $182 | $182 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $207 | $207 | $207 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $69 | $227 | $385 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $73 | $229 | $385 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $80 | $232 | $385 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $61 | $105 | $148 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $86 | $115 | $143 |
| Ultrasound transvaginal CPT 76830 • Imaging | $66 | $92 | $119 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $57 | $65 | $73 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $32 | $74 | $116 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $40 | $126 | $212 |
| Screening mammography bilateral CPT 77067 • Imaging | $48 | $76 | $104 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $23 | $23 | $23 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $305 | $385 | $465 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $7 | $7 | $7 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |