| CT head without then with contrast CPT 70470 • Imaging | $99 | $99 | $99 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $35 | $41 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $61 | $67 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $50 | $66 |
| CT angiography neck CPT 70498 • Imaging | $30 | $187 | $446 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $73 | $128 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $138 | $199 |
| MRI brain with contrast CPT 70552 • Imaging | $107 | $107 | $107 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $221 | $420 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $12 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $17 | $24 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $82 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $63 | $128 | $168 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $106 | $181 |
| CT angiography chest CPT 71275 • Imaging | $87 | $218 | $348 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $45 | $56 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $39 | $49 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $100 | $221 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $158 | $250 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $116 | $195 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $71 | $77 | $89 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $59 | $65 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $133 | $313 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $24 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $137 | $209 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $26 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $23 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $65 | $73 | $81 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $203 | $302 | $497 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $118 | $268 |
| CT abdomen with contrast CPT 74160 • Imaging | $61 | $61 | $61 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $235 | $411 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $121 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $99 | $258 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $271 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $36 | $85 | $116 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $51 | $80 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $79 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $30 | $88 | $126 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $95 | $154 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $76 | $125 | $160 |
| Screening mammography bilateral CPT 77067 • Imaging | $107 | $115 | $128 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $40 | $70 | $101 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $78 | $370 | $690 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $4 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $4 | $4 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |