| CT head without then with contrast CPT 70470 • Imaging | $183 | $183 | $183 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $42 | $42 | $42 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $160 | $160 | $160 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $67 | $69 |
| CT angiography neck CPT 70498 • Imaging | $87 | $87 | $87 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $107 | $107 | $107 |
| MRI brain without contrast CPT 70551 • Imaging | $74 | $160 | $203 |
| MRI brain with contrast CPT 70552 • Imaging | $192 | $228 | $279 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $358 | $358 | $358 |
| Chest X-ray single view CPT 71045 • Imaging | $19 | $22 | $24 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $51 | $79 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $217 | $217 | $217 |
| CT chest without then with contrast CPT 71270 • Imaging | $192 | $196 | $200 |
| CT angiography chest CPT 71275 • Imaging | $257 | $271 | $285 |
| CT cervical spine without contrast CPT 72125 • Imaging | $175 | $175 | $175 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $121 | $121 | $121 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $50 | $50 | $50 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $74 | $123 | $197 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $124 | $132 | $139 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $198 | $205 | $212 |
| CT pelvis without contrast CPT 72192 • Imaging | $139 | $139 | $139 |
| CT pelvis with contrast CPT 72193 • Imaging | $58 | $142 | $226 |
| X-ray shoulder complete CPT 73030 • Imaging | $24 | $28 | $32 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $67 | $79 | $103 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $21 | $26 | $31 |
| X-ray ankle complete CPT 73610 • Imaging | $21 | $27 | $34 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $277 | $277 | $277 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $65 | $143 | $224 |
| CT abdomen without contrast CPT 74150 • Imaging | $84 | $110 | $137 |
| CT abdomen with contrast CPT 74160 • Imaging | $219 | $219 | $219 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $70 | $70 | $70 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $188 | $192 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $295 | $304 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $264 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $69 | $85 | $108 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $72 | $86 | $100 |
| Ultrasound transvaginal CPT 76830 • Imaging | $82 | $96 | $110 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $49 | $63 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $34 | $36 | $39 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $147 | $154 | $161 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $51 | $84 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $39 | $39 | $39 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $284 | $462 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $5 | $8 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $4 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |