| CT maxillofacial without contrast CPT 70486 • Imaging | $180 | $180 | $180 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $141 | $141 | $141 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $169 | $169 | $169 |
| CT angiography neck CPT 70498 • Imaging | $262 | $262 | $262 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $368 | $368 | $368 |
| MRI brain without contrast CPT 70551 • Imaging | $293 | $293 | $293 |
| MRI brain with contrast CPT 70552 • Imaging | $120 | $120 | $120 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $326 | $326 | $326 |
| Chest X-ray single view CPT 71045 • Imaging | $12 | $12 | $12 |
| Chest X-ray 2 views CPT 71046 • Imaging | $26 | $26 | $26 |
| CT chest without contrast CPT 71250 • Imaging | $205 | $205 | $205 |
| CT chest with contrast CPT 71260 • Imaging | $84 | $84 | $84 |
| CT chest without then with contrast CPT 71270 • Imaging | $208 | $208 | $208 |
| CT angiography chest CPT 71275 • Imaging | $267 | $267 | $267 |
| CT cervical spine without contrast CPT 72125 • Imaging | $72 | $72 | $72 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $165 | $165 | $165 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $232 | $232 | $232 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $186 | $186 | $186 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $100 | $100 | $100 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $186 | $186 | $186 |
| CT pelvis without contrast CPT 72192 • Imaging | $73 | $73 | $73 |
| CT pelvis with contrast CPT 72193 • Imaging | $78 | $78 | $78 |
| X-ray shoulder complete CPT 73030 • Imaging | $13 | $13 | $13 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $209 | $209 | $209 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $30 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $31 | $31 | $31 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $91 | $91 | $91 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $209 | $209 | $209 |
| CT abdomen without contrast CPT 74150 • Imaging | $114 | $114 | $114 |
| CT abdomen with contrast CPT 74160 • Imaging | $308 | $308 | $308 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $349 | $349 | $349 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $261 | $261 | $261 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $289 | $289 | $289 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $135 | $135 | $135 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $54 | $54 | $54 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $96 | $96 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $158 | $158 | $158 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $95 | $95 | $95 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $55 | $55 | $55 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $151 | $151 | $151 |
| Screening mammography bilateral CPT 77067 • Imaging | $51 | $51 | $51 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $52 | $52 | $52 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $514 | $514 | $514 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $5 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $7 | $7 | $7 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |