| CT head without then with contrast CPT 70470 • Imaging | $52 | $52 | $52 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $63 | $63 | $63 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $37 | $37 | $37 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $43 | $113 | $183 |
| CT angiography neck CPT 70498 • Imaging | $239 | $239 | $239 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $305 | $305 | $305 |
| MRI brain without contrast CPT 70551 • Imaging | $135 | $320 | $425 |
| MRI brain with contrast CPT 70552 • Imaging | $176 | $301 | $425 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $39 | $232 | $425 |
| Chest X-ray single view CPT 71045 • Imaging | $6 | $17 | $25 |
| Chest X-ray 2 views CPT 71046 • Imaging | $7 | $17 | $27 |
| CT chest without contrast CPT 71250 • Imaging | $80 | $113 | $131 |
| CT chest with contrast CPT 71260 • Imaging | $55 | $67 | $78 |
| CT chest without then with contrast CPT 71270 • Imaging | $56 | $126 | $196 |
| CT angiography chest CPT 71275 • Imaging | $67 | $171 | $275 |
| CT cervical spine without contrast CPT 72125 • Imaging | $69 | $69 | $69 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $31 | $31 | $31 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $57 | $57 | $57 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $169 | $331 | $425 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $142 | $212 | $281 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $47 | $236 | $425 |
| CT pelvis without contrast CPT 72192 • Imaging | $95 | $95 | $95 |
| CT pelvis with contrast CPT 72193 • Imaging | $96 | $160 | $224 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $27 | $33 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $150 | $288 | $425 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $16 | $21 | $25 |
| X-ray ankle complete CPT 73610 • Imaging | $28 | $32 | $36 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $42 | $42 | $42 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $85 | $235 | $425 |
| CT abdomen without contrast CPT 74150 • Imaging | $44 | $159 | $275 |
| CT abdomen with contrast CPT 74160 • Imaging | $42 | $42 | $42 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $23 | $23 | $23 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $54 | $165 | $275 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $264 | $281 | $306 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $275 | $302 | $342 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $25 | $58 | $91 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $50 | $67 | $84 |
| Ultrasound transvaginal CPT 76830 • Imaging | $71 | $82 | $92 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $49 | $70 | $91 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $84 | $103 | $120 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $89 | $105 | $121 |
| Screening mammography bilateral CPT 77067 • Imaging | $36 | $90 | $123 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $19 | $19 | $19 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $52 | $241 | $429 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $6 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $7 | $9 |
| Lipid panel CPT 80061 • Laboratory | $5 | $8 | $10 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $3 | $3 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |