| CT head without then with contrast CPT 70470 • Imaging | $196 | $196 | $196 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $57 | $85 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $260 | $260 | $260 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $190 | $350 |
| CT angiography neck CPT 70498 • Imaging | $30 | $279 | $529 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $94 | $159 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $140 | $240 |
| MRI brain with contrast CPT 70552 • Imaging | $342 | $342 | $342 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $295 | $561 |
| Chest X-ray single view CPT 71045 • Imaging | $15 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $16 | $16 | $16 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $53 | $75 |
| CT chest with contrast CPT 71260 • Imaging | $92 | $92 | $92 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $66 | $102 |
| CT angiography chest CPT 71275 • Imaging | $389 | $389 | $389 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $115 | $200 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $52 | $74 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $114 | $198 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $70 | $111 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $189 | $347 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $70 | $111 |
| CT pelvis without contrast CPT 72192 • Imaging | $216 | $216 | $216 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $139 | $248 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $260 | $260 | $260 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $14 | $22 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $33 | $35 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $421 | $421 | $421 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $206 | $234 | $261 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $81 | $133 |
| CT abdomen with contrast CPT 74160 • Imaging | $94 | $94 | $94 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $160 | $291 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $181 | $181 | $181 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $388 | $462 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $351 | $444 | $538 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $60 | $60 | $60 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $42 | $55 |
| Ultrasound transvaginal CPT 76830 • Imaging | $51 | $51 | $51 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $51 | $51 | $51 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $58 | $84 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $241 | $241 | $241 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $126 | $140 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $69 | $69 | $69 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $537 | $683 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $9 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $12 | $12 | $12 |
| Lipid panel CPT 80061 • Laboratory | $11 | $14 | $18 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $9 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $4 |