| CT head without then with contrast CPT 70470 • Imaging | $63 | $63 | $63 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $43 | $43 | $43 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $160 | $160 | $160 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $69 | $166 | $262 |
| CT angiography neck CPT 70498 • Imaging | $87 | $87 | $87 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $273 | $273 | $273 |
| MRI brain without contrast CPT 70551 • Imaging | $74 | $450 | $638 |
| MRI brain with contrast CPT 70552 • Imaging | $301 | $469 | $638 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $114 | $114 | $114 |
| Chest X-ray single view CPT 71045 • Imaging | $15 | $24 | $29 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $22 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $152 | $176 | $188 |
| CT chest with contrast CPT 71260 • Imaging | $21 | $41 | $62 |
| CT chest without then with contrast CPT 71270 • Imaging | $154 | $217 | $281 |
| CT angiography chest CPT 71275 • Imaging | $289 | $323 | $357 |
| CT cervical spine without contrast CPT 72125 • Imaging | $123 | $123 | $123 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $172 | $172 | $172 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $172 | $172 | $172 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $212 | $496 | $638 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $21 | $48 | $74 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $212 | $425 | $638 |
| CT pelvis without contrast CPT 72192 • Imaging | $85 | $85 | $85 |
| CT pelvis with contrast CPT 72193 • Imaging | $165 | $240 | $314 |
| X-ray shoulder complete CPT 73030 • Imaging | $19 | $32 | $38 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $223 | $223 | $223 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $22 | $30 | $38 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $25 | $41 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $67 | $353 | $638 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $68 | $353 | $638 |
| CT abdomen without contrast CPT 74150 • Imaging | $84 | $139 | $194 |
| CT abdomen with contrast CPT 74160 • Imaging | $228 | $228 | $228 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $258 | $258 | $258 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $193 | $225 | $258 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $305 | $394 | $439 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $245 | $409 | $491 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $40 | $86 | $131 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $79 | $121 |
| Ultrasound transvaginal CPT 76830 • Imaging | $117 | $125 | $134 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $36 | $70 | $105 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $41 | $74 | $140 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $112 | $144 | $176 |
| Screening mammography bilateral CPT 77067 • Imaging | $38 | $73 | $143 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $414 | $437 | $459 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $7 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $11 | $16 |
| Lipid panel CPT 80061 • Laboratory | $7 | $14 | $20 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $5 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $3 |