| CT head without then with contrast CPT 70470 • Imaging | $124 | $124 | $124 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $56 | $83 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $314 | $314 | $314 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $166 | $303 |
| CT angiography neck CPT 70498 • Imaging | $30 | $203 | $376 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $172 | $348 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $146 | $284 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $324 | $420 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $353 | $702 |
| Chest X-ray single view CPT 71045 • Imaging | $18 | $21 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $20 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $61 | $99 |
| CT chest with contrast CPT 71260 • Imaging | $30 | $149 | $304 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $203 | $376 |
| CT angiography chest CPT 71275 • Imaging | $255 | $356 | $558 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $186 | $342 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $182 | $334 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $64 | $97 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $141 | $195 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $209 | $416 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $209 | $414 |
| CT pelvis without contrast CPT 72192 • Imaging | $273 | $273 | $273 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $224 | $419 |
| X-ray shoulder complete CPT 73030 • Imaging | $21 | $27 | $35 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $141 | $289 | $438 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $22 | $32 | $54 |
| X-ray ankle complete CPT 73610 • Imaging | $18 | $24 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $279 | $544 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $203 | $437 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $90 | $164 |
| CT abdomen with contrast CPT 74160 • Imaging | $304 | $304 | $304 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $83 | $136 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $103 | $194 | $375 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $335 | $401 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $378 | $459 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $79 | $95 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $75 | $141 |
| Ultrasound transvaginal CPT 76830 • Imaging | $68 | $73 | $75 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $93 | $108 | $139 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $34 | $117 | $249 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $95 | $96 | $96 |
| Screening mammography bilateral CPT 77067 • Imaging | $72 | $94 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $77 | $77 | $77 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $400 | $750 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $6 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $7 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $9 | $12 |
| Lipid panel CPT 80061 • Laboratory | $10 | $12 | $18 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $8 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $4 |