| CT head with contrast CPT 70460 • Imaging | $198 | $198 | $198 |
| CT head without then with contrast CPT 70470 • Imaging | $209 | $209 | $209 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $208 | $208 | $208 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $254 | $254 | $254 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $75 | $125 | $174 |
| CT angiography neck CPT 70498 • Imaging | $524 | $524 | $524 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $709 | $709 | $709 |
| MRI brain without contrast CPT 70551 • Imaging | $186 | $271 | $440 |
| MRI brain with contrast CPT 70552 • Imaging | $257 | $419 | $582 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $707 | $707 | $707 |
| Chest X-ray single view CPT 71045 • Imaging | $11 | $18 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $20 | $32 |
| CT chest without contrast CPT 71250 • Imaging | $126 | $150 | $198 |
| CT chest with contrast CPT 71260 • Imaging | $158 | $203 | $247 |
| CT chest without then with contrast CPT 71270 • Imaging | $75 | $84 | $92 |
| CT angiography chest CPT 71275 • Imaging | $104 | $173 | $241 |
| CT cervical spine without contrast CPT 72125 • Imaging | $258 | $258 | $258 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $55 | $55 | $55 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $253 | $253 | $253 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $87 | $150 | $182 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $68 | $269 | $470 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $81 | $131 | $182 |
| CT pelvis without contrast CPT 72192 • Imaging | $245 | $245 | $245 |
| CT pelvis with contrast CPT 72193 • Imaging | $212 | $255 | $298 |
| X-ray shoulder complete CPT 73030 • Imaging | $11 | $23 | $29 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $62 | $238 | $414 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $24 | $26 | $28 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $33 | $37 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $212 | $359 | $506 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $129 | $249 | $425 |
| CT abdomen without contrast CPT 74150 • Imaging | $65 | $97 | $130 |
| CT abdomen with contrast CPT 74160 • Imaging | $69 | $69 | $69 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $76 | $76 | $76 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $175 | $210 | $245 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $284 | $287 | $289 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $318 | $377 | $489 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $96 | $125 | $155 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $89 | $98 | $107 |
| Ultrasound transvaginal CPT 76830 • Imaging | $98 | $100 | $102 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $58 | $98 | $138 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $33 | $78 | $106 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $52 | $91 | $130 |
| Screening mammography bilateral CPT 77067 • Imaging | $31 | $93 | $141 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $11 | $11 | $11 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $86 | $220 | $355 |
| 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 | $7 | $7 | $7 |
| Lipid panel CPT 80061 • Laboratory | $2 | $8 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |