| CT head without then with contrast CPT 70470 • Imaging | $313 | $313 | $313 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $146 | $262 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $246 | $246 | $246 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $134 | $237 |
| CT angiography neck CPT 70498 • Imaging | $30 | $62 | $93 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $393 | $755 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $253 | $518 |
| MRI brain with contrast CPT 70552 • Imaging | $485 | $485 | $485 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $290 | $624 |
| Chest X-ray single view CPT 71045 • Imaging | $11 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $20 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $142 | $262 |
| CT chest with contrast CPT 71260 • Imaging | $66 | $66 | $66 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $52 | $73 |
| CT angiography chest CPT 71275 • Imaging | $255 | $384 | $513 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $46 | $62 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $46 | $62 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $46 | $62 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $251 | $472 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $103 | $195 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $213 | $396 |
| CT pelvis without contrast CPT 72192 • Imaging | $247 | $247 | $247 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $133 | $235 |
| X-ray shoulder complete CPT 73030 • Imaging | $20 | $27 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $417 | $417 | $417 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $23 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $20 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $436 | $436 | $436 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $206 | $352 | $498 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $140 | $251 |
| CT abdomen with contrast CPT 74160 • Imaging | $68 | $68 | $68 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $52 | $75 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $212 | $239 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $276 | $301 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $355 | $365 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $44 | $73 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $86 | $133 |
| Ultrasound transvaginal CPT 76830 • Imaging | $105 | $114 | $123 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $34 | $37 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $125 | $154 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $167 | $195 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $113 | $114 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $322 | $390 | $456 |
| 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 | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $10 | $10 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |