| CT head with contrast CPT 70460 • Imaging | $30 | $30 | $30 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $30 | $30 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $30 | $30 |
| CT angiography neck CPT 70498 • Imaging | $30 | $30 | $30 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $189 | $348 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $120 | $200 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $276 | $276 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $69 | $108 |
| Chest X-ray single view CPT 71045 • Imaging | $22 | $22 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $19 | $19 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $82 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $113 | $113 | $113 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $255 | $255 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $30 | $30 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $30 | $30 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $30 | $30 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $113 | $195 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $50 | $70 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $113 | $196 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $30 | $30 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $206 | $206 | $206 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $30 | $30 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $118 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $85 | $139 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $185 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $313 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $350 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $103 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $63 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $105 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $30 | $30 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $110 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $139 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $72 | $112 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $230 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $8 | $8 |
| Lipid panel CPT 80061 • Laboratory | $11 | $11 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $13 | $13 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $23 | $23 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |