| CT head without then with contrast CPT 70470 • Imaging | $60 | $60 | $60 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $41 | $41 | $41 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $55 | $55 | $55 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $111 | $191 |
| CT angiography neck CPT 70498 • Imaging | $201 | $201 | $201 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $148 | $266 |
| MRI brain without contrast CPT 70551 • Imaging | $30 | $125 | $215 |
| MRI brain with contrast CPT 70552 • Imaging | $85 | $180 | $276 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $326 | $335 | $345 |
| Chest X-ray single view CPT 71045 • Imaging | $22 | $23 | $24 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $25 | $32 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $70 | $149 |
| CT chest with contrast CPT 71260 • Imaging | $168 | $179 | $189 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $48 | $65 |
| CT angiography chest CPT 71275 • Imaging | $200 | $227 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $48 | $48 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $101 | $101 | $101 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $149 | $149 | $149 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $120 | $195 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $82 | $134 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $137 | $167 | $196 |
| CT pelvis without contrast CPT 72192 • Imaging | $137 | $137 | $137 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $102 | $174 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $20 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $65 | $65 | $65 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $22 | $27 | $32 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $31 | $33 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $65 | $65 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $125 | $221 |
| CT abdomen without contrast CPT 74150 • Imaging | $82 | $83 | $84 |
| CT abdomen with contrast CPT 74160 • Imaging | $177 | $177 | $177 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $67 | $67 | $67 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $85 | $94 | $103 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $238 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $266 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $110 | $116 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $64 | $68 | $72 |
| Ultrasound transvaginal CPT 76830 • Imaging | $75 | $97 | $119 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $73 | $83 | $93 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $88 | $103 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $96 | $130 | $163 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $107 | $130 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $38 | $38 | $38 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $376 | $383 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $4 | $4 |
| Lipid panel CPT 80061 • Laboratory | $5 | $5 | $6 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $3 | $3 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |