| CT head without then with contrast CPT 70470 • Imaging | $55 | $55 | $55 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $120 | $120 | $120 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $95 | $95 | $95 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $115 | $115 | $115 |
| CT angiography neck CPT 70498 • Imaging | $256 | $256 | $256 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $243 | $243 | $243 |
| MRI brain without contrast CPT 70551 • Imaging | $193 | $193 | $193 |
| MRI brain with contrast CPT 70552 • Imaging | $189 | $189 | $189 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $215 | $215 | $215 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $8 | $8 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $19 | $19 |
| CT chest without contrast CPT 71250 • Imaging | $50 | $50 | $50 |
| CT chest with contrast CPT 71260 • Imaging | $54 | $54 | $54 |
| CT chest without then with contrast CPT 71270 • Imaging | $141 | $141 | $141 |
| CT angiography chest CPT 71275 • Imaging | $79 | $79 | $79 |
| CT cervical spine without contrast CPT 72125 • Imaging | $44 | $44 | $44 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $91 | $91 | $91 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $44 | $44 | $44 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $187 | $187 | $187 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $187 | $187 | $187 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $123 | $123 | $123 |
| CT pelvis without contrast CPT 72192 • Imaging | $47 | $47 | $47 |
| CT pelvis with contrast CPT 72193 • Imaging | $209 | $209 | $209 |
| X-ray shoulder complete CPT 73030 • Imaging | $29 | $29 | $29 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $139 | $139 | $139 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $21 | $21 | $21 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $30 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $164 | $164 | $164 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $198 | $198 | $198 |
| CT abdomen without contrast CPT 74150 • Imaging | $129 | $129 | $129 |
| CT abdomen with contrast CPT 74160 • Imaging | $214 | $214 | $214 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $61 | $61 | $61 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $76 | $76 | $76 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $79 | $79 | $79 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $87 | $87 | $87 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $106 | $106 | $106 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $98 | $98 | $98 |
| Ultrasound transvaginal CPT 76830 • Imaging | $76 | $76 | $76 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $95 | $95 | $95 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $116 | $116 | $116 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $102 | $102 | $102 |
| Screening mammography bilateral CPT 77067 • Imaging | $118 | $118 | $118 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $25 | $25 | $25 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $412 | $412 | $412 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $4 | $4 |
| Lipid panel CPT 80061 • Laboratory | $6 | $6 | $6 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $3 | $3 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |