| CT head without then with contrast CPT 70470 • Imaging | $256 | $256 | $256 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $228 | $228 | $228 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $205 | $205 | $205 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $188 | $197 | $205 |
| CT angiography neck CPT 70498 • Imaging | $385 | $385 | $385 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $246 | $622 | $999 |
| MRI brain without contrast CPT 70551 • Imaging | $200 | $269 | $406 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $426 | $577 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $466 | $902 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $18 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $14 | $20 |
| CT chest without contrast CPT 71250 • Imaging | $67 | $158 | $273 |
| CT chest with contrast CPT 71260 • Imaging | $30 | $143 | $256 |
| CT chest without then with contrast CPT 71270 • Imaging | $200 | $261 | $321 |
| CT angiography chest CPT 71275 • Imaging | $255 | $349 | $442 |
| CT cervical spine without contrast CPT 72125 • Imaging | $214 | $214 | $214 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $273 | $273 | $273 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $58 | $58 | $58 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $195 | $266 | $406 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $531 | $531 | $531 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $196 | $323 | $451 |
| CT pelvis without contrast CPT 72192 • Imaging | $214 | $214 | $214 |
| CT pelvis with contrast CPT 72193 • Imaging | $224 | $265 | $306 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $23 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $233 | $401 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $28 | $29 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $29 | $30 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $68 | $148 | $229 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $201 | $469 |
| CT abdomen without contrast CPT 74150 • Imaging | $60 | $99 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $64 | $64 | $64 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $307 | $307 | $307 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $206 | $226 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $258 | $295 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $341 | $347 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $74 | $88 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $96 | $104 | $112 |
| Ultrasound transvaginal CPT 76830 • Imaging | $36 | $70 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $43 | $57 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $34 | $80 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $139 | $158 | $177 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $111 | $143 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $91 | $91 | $91 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $138 | $265 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |