| CT angiography neck CPT 70498 • Imaging | $484 | $484 | $484 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $157 | $157 | $157 |
| MRI brain without contrast CPT 70551 • Imaging | $108 | $108 | $108 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $168 | $168 | $168 |
| Chest X-ray single view CPT 71045 • Imaging | $13 | $13 | $13 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $89 | $89 | $89 |
| CT chest with contrast CPT 71260 • Imaging | $86 | $86 | $86 |
| CT angiography chest CPT 71275 • Imaging | $133 | $133 | $133 |
| CT cervical spine without contrast CPT 72125 • Imaging | $74 | $74 | $74 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $74 | $74 | $74 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $73 | $73 | $73 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $114 | $114 | $114 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $109 | $109 | $109 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $362 | $362 | $362 |
| CT pelvis without contrast CPT 72192 • Imaging | $80 | $80 | $80 |
| CT pelvis with contrast CPT 72193 • Imaging | $85 | $85 | $85 |
| X-ray shoulder complete CPT 73030 • Imaging | $55 | $55 | $55 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $387 | $387 | $387 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $14 | $14 | $14 |
| X-ray ankle complete CPT 73610 • Imaging | $46 | $46 | $46 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $98 | $98 | $98 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $99 | $99 | $99 |
| CT abdomen without contrast CPT 74150 • Imaging | $87 | $87 | $87 |
| CT abdomen with contrast CPT 74160 • Imaging | $93 | $93 | $93 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $487 | $487 | $487 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $127 | $127 | $127 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $566 | $566 | $566 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $146 | $146 | $146 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $59 | $59 | $59 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $54 | $54 | $54 |
| Ultrasound transvaginal CPT 76830 • Imaging | $57 | $57 | $57 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $52 | $52 | $52 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $117 | $117 | $117 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $74 | $74 | $74 |
| Screening mammography bilateral CPT 77067 • Imaging | $63 | $63 | $63 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $15 | $15 | $15 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $120 | $120 | $120 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $15 | $15 | $15 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $5 | $5 |
| Lipid panel CPT 80061 • Laboratory | $5 | $5 | $5 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $5 | $5 | $5 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $5 | $5 | $5 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $3 | $4 | $5 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $5 | $5 | $5 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $5 | $5 | $5 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $5 | $5 | $5 |
| Creatinine urine CPT 82570 • Laboratory | $5 | $5 | $5 |