| CT maxillofacial without contrast CPT 70486 • Imaging | $318 | $318 | $318 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $307 | $307 | $307 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $299 | $299 | $299 |
| CT angiography neck CPT 70498 • Imaging | $718 | $718 | $718 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $42 | $83 | $125 |
| MRI brain without contrast CPT 70551 • Imaging | $86 | $340 | $595 |
| MRI brain with contrast CPT 70552 • Imaging | $104 | $349 | $595 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $419 | $692 | $966 |
| Chest X-ray single view CPT 71045 • Imaging | $13 | $19 | $25 |
| Chest X-ray 2 views CPT 71046 • Imaging | $24 | $24 | $24 |
| CT chest without contrast CPT 71250 • Imaging | $339 | $362 | $385 |
| CT chest with contrast CPT 71260 • Imaging | $42 | $223 | $405 |
| CT chest without then with contrast CPT 71270 • Imaging | $419 | $419 | $419 |
| CT angiography chest CPT 71275 • Imaging | $385 | $456 | $527 |
| CT cervical spine without contrast CPT 72125 • Imaging | $67 | $67 | $67 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $67 | $67 | $67 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $272 | $272 | $272 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $595 | $607 | $619 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $419 | $487 | $555 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $554 | $575 | $595 |
| CT pelvis without contrast CPT 72192 • Imaging | $327 | $327 | $327 |
| CT pelvis with contrast CPT 72193 • Imaging | $318 | $318 | $318 |
| X-ray shoulder complete CPT 73030 • Imaging | $25 | $33 | $42 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $419 | $521 | $624 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $34 | $38 | $42 |
| X-ray ankle complete CPT 73610 • Imaging | $25 | $25 | $26 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $595 | $617 | $640 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $553 | $574 | $595 |
| CT abdomen without contrast CPT 74150 • Imaging | $327 | $356 | $385 |
| CT abdomen with contrast CPT 74160 • Imaging | $74 | $74 | $74 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $81 | $81 | $81 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $285 | $335 | $385 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $120 | $252 | $385 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $133 | $259 | $385 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $47 | $98 | $148 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $105 | $124 | $143 |
| Ultrasound transvaginal CPT 76830 • Imaging | $119 | $126 | $132 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $106 | $119 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $116 | $159 | $201 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $76 | $144 | $212 |
| Screening mammography bilateral CPT 77067 • Imaging | $48 | $53 | $58 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $143 | $254 | $366 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $5 | $5 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $11 | $17 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $12 | $15 | $18 |
| Lipid panel CPT 80061 • Laboratory | $9 | $23 | $30 |
| Hepatic function panel CPT 80076 • Laboratory | $11 | $14 | $17 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $4 | $7 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $4 | $5 |