| CT head without then with contrast CPT 70470 • Imaging | $174 | $174 | $174 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $70 | $100 | $131 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $91 | $121 | $150 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $55 | $116 | $181 |
| CT angiography neck CPT 70498 • Imaging | $128 | $132 | $136 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $157 | $363 | $569 |
| MRI brain without contrast CPT 70551 • Imaging | $109 | $235 | $388 |
| MRI brain with contrast CPT 70552 • Imaging | $430 | $439 | $449 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $184 | $262 | $340 |
| Chest X-ray single view CPT 71045 • Imaging | $13 | $16 | $18 |
| Chest X-ray 2 views CPT 71046 • Imaging | $8 | $19 | $33 |
| CT chest without contrast CPT 71250 • Imaging | $55 | $83 | $136 |
| CT chest with contrast CPT 71260 • Imaging | $94 | $138 | $182 |
| CT chest without then with contrast CPT 71270 • Imaging | $55 | $189 | $323 |
| CT angiography chest CPT 71275 • Imaging | $142 | $309 | $422 |
| CT cervical spine without contrast CPT 72125 • Imaging | $81 | $112 | $144 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $77 | $147 | $217 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $73 | $75 | $77 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $119 | $322 | $659 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $119 | $344 | $718 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $120 | $378 | $711 |
| CT pelvis without contrast CPT 72192 • Imaging | $80 | $80 | $80 |
| CT pelvis with contrast CPT 72193 • Imaging | $55 | $153 | $251 |
| X-ray shoulder complete CPT 73030 • Imaging | $13 | $28 | $41 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $93 | $97 | $101 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $34 | $39 | $44 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $20 | $37 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $259 | $316 | $374 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $123 | $225 | $334 |
| CT abdomen without contrast CPT 74150 • Imaging | $87 | $181 | $275 |
| CT abdomen with contrast CPT 74160 • Imaging | $94 | $94 | $94 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $387 | $387 | $387 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $135 | $260 | $363 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $142 | $370 | $633 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $55 | $415 | $825 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $60 | $74 | $98 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $60 | $103 | $158 |
| Ultrasound transvaginal CPT 76830 • Imaging | $57 | $117 | $172 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $50 | $69 | $88 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $33 | $96 | $128 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $73 | $95 | $131 |
| Screening mammography bilateral CPT 77067 • Imaging | $56 | $93 | $148 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $40 | $40 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $65 | $282 | $658 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $4 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $9 | $13 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $8 | $9 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $7 | $10 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $6 |