| CT angiography neck CPT 70498 • Imaging | $474 | $474 | $474 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $304 | $598 | $893 |
| MRI brain without contrast CPT 70551 • Imaging | $198 | $340 | $482 |
| MRI brain with contrast CPT 70552 • Imaging | $290 | $434 | $578 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $304 | $664 | $1,023 |
| Chest X-ray single view CPT 71045 • Imaging | $20 | $23 | $26 |
| Chest X-ray 2 views CPT 71046 • Imaging | $31 | $33 | $35 |
| CT chest without contrast CPT 71250 • Imaging | $89 | $152 | $215 |
| CT chest with contrast CPT 71260 • Imaging | $152 | $205 | $257 |
| CT chest without then with contrast CPT 71270 • Imaging | $70 | $70 | $70 |
| CT angiography chest CPT 71275 • Imaging | $97 | $125 | $152 |
| CT cervical spine without contrast CPT 72125 • Imaging | $273 | $273 | $273 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $58 | $58 | $58 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $58 | $58 | $58 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $188 | $297 | $407 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $189 | $361 | $533 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $189 | $320 | $452 |
| CT pelvis without contrast CPT 72192 • Imaging | $215 | $215 | $215 |
| CT pelvis with contrast CPT 72193 • Imaging | $58 | $58 | $58 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $21 | $21 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $68 | $137 | $205 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $9 | $9 |
| X-ray ankle complete CPT 73610 • Imaging | $28 | $28 | $28 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $68 | $137 | $205 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $68 | $137 | $205 |
| CT abdomen without contrast CPT 74150 • Imaging | $266 | $266 | $266 |
| CT abdomen with contrast CPT 74160 • Imaging | $249 | $249 | $249 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $379 | $379 | $379 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $159 | $193 | $227 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $259 | $281 | $304 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $304 | $323 | $343 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $89 | $101 | $113 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $63 | $89 |
| Ultrasound transvaginal CPT 76830 • Imaging | $89 | $90 | $91 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $35 | $62 | $89 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $41 | $41 | $41 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $119 | $119 | $119 |
| Screening mammography bilateral CPT 77067 • Imaging | $98 | $98 | $98 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $102 | $102 | $102 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $543 | $833 | $1,123 |
| 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 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $16 | $16 | $16 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $21 | $21 | $21 |