| CT head without then with contrast CPT 70470 • Imaging | $53 | $53 | $53 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $181 | $181 | $181 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $221 | $221 | $221 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $188 | $202 | $216 |
| CT angiography neck CPT 70498 • Imaging | $74 | $74 | $74 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $246 | $472 | $697 |
| MRI brain without contrast CPT 70551 • Imaging | $200 | $270 | $410 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $408 | $540 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $326 | $511 | $695 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $18 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $17 | $23 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $134 | $171 | $244 |
| CT chest with contrast CPT 71260 • Imaging | $55 | $147 | $240 |
| CT chest without then with contrast CPT 71270 • Imaging | $58 | $129 | $200 |
| CT angiography chest CPT 71275 • Imaging | $255 | $317 | $380 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $48 | $48 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $196 | $196 | $196 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $48 | $48 | $48 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $195 | $279 | $445 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $48 | $67 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $196 | $298 | $399 |
| CT pelvis without contrast CPT 72192 • Imaging | $235 | $235 | $235 |
| CT pelvis with contrast CPT 72193 • Imaging | $49 | $136 | $224 |
| X-ray shoulder complete CPT 73030 • Imaging | $8 | $23 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $56 | $56 | $56 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $17 | $23 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $7 | $23 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $229 | $345 | $461 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $65 | $223 | $398 |
| CT abdomen without contrast CPT 74150 • Imaging | $50 | $95 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $54 | $54 | $54 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $387 | $387 | $387 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $195 | $205 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $316 | $320 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $96 | $265 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $34 | $68 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $76 | $86 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $66 | $86 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $61 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $114 | $121 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $107 | $123 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $105 | $123 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $78 | $78 | $78 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $322 | $433 | $544 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |