| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $100 | $100 | $100 |
| MRI brain without contrast CPT 70551 • Imaging | $195 | $195 | $195 |
| MRI brain with contrast CPT 70552 • Imaging | $186 | $186 | $186 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $211 | $220 | $230 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $14 | $20 |
| Chest X-ray 2 views CPT 71046 • Imaging | $22 | $24 | $27 |
| CT chest without contrast CPT 71250 • Imaging | $68 | $75 | $82 |
| CT chest with contrast CPT 71260 • Imaging | $115 | $140 | $165 |
| CT chest without then with contrast CPT 71270 • Imaging | $58 | $58 | $58 |
| CT angiography chest CPT 71275 • Imaging | $85 | $100 | $115 |
| CT cervical spine without contrast CPT 72125 • Imaging | $128 | $128 | $128 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $46 | $46 | $46 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $82 | $82 | $82 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $190 | $190 | $190 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $69 | $106 | $143 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $121 | $132 | $143 |
| CT pelvis without contrast CPT 72192 • Imaging | $132 | $132 | $132 |
| CT pelvis with contrast CPT 72193 • Imaging | $54 | $54 | $54 |
| X-ray shoulder complete CPT 73030 • Imaging | $24 | $24 | $24 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $156 | $178 | $201 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $8 | $8 |
| X-ray ankle complete CPT 73610 • Imaging | $35 | $35 | $35 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $63 | $109 | $156 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $156 | $178 | $201 |
| CT abdomen without contrast CPT 74150 • Imaging | $68 | $74 | $80 |
| CT abdomen with contrast CPT 74160 • Imaging | $173 | $173 | $173 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $65 | $65 | $65 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $101 | $111 | $120 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $230 | $266 | $303 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $230 | $238 | $246 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $68 | $90 | $112 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $34 | $51 | $68 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $50 | $68 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $68 | $84 | $101 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $38 | $38 | $38 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $105 | $105 | $105 |
| Screening mammography bilateral CPT 77067 • Imaging | $123 | $123 | $123 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $9 | $9 | $9 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $341 | $341 | $341 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $4 | $4 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $6 | $9 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $10 | $12 | $13 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $12 | $20 | $24 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $3 | $4 | $5 |