| CT maxillofacial without contrast CPT 70486 • Imaging | $133 | $133 | $133 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $56 | $56 | $56 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $224 | $224 | $224 |
| CT angiography neck CPT 70498 • Imaging | $192 | $192 | $192 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $13 | $239 | $465 |
| MRI brain without contrast CPT 70551 • Imaging | $13 | $43 | $74 |
| MRI brain with contrast CPT 70552 • Imaging | $13 | $158 | $303 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $89 | $102 | $114 |
| Chest X-ray single view CPT 71045 • Imaging | $19 | $22 | $25 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $14 | $17 |
| CT chest without contrast CPT 71250 • Imaging | $13 | $92 | $171 |
| CT chest with contrast CPT 71260 • Imaging | $191 | $204 | $217 |
| CT chest without then with contrast CPT 71270 • Imaging | $69 | $69 | $69 |
| CT angiography chest CPT 71275 • Imaging | $13 | $149 | $285 |
| CT cervical spine without contrast CPT 72125 • Imaging | $122 | $122 | $122 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $50 | $50 | $50 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $120 | $120 | $120 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $13 | $76 | $139 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $74 | $170 | $265 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $13 | $76 | $138 |
| CT pelvis without contrast CPT 72192 • Imaging | $139 | $139 | $139 |
| CT pelvis with contrast CPT 72193 • Imaging | $156 | $156 | $156 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $11 | $13 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $156 | $236 | $315 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $13 | $21 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $16 | $23 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $13 | $179 | $344 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $51 | $59 | $68 |
| CT abdomen without contrast CPT 74150 • Imaging | $13 | $48 | $84 |
| CT abdomen with contrast CPT 74160 • Imaging | $63 | $63 | $63 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $70 | $70 | $70 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $87 | $211 | $336 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $91 | $304 | $518 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $235 | $411 | $588 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $13 | $45 | $77 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $13 | $43 | $72 |
| Ultrasound transvaginal CPT 76830 • Imaging | $13 | $24 | $34 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $164 | $295 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $88 | $99 | $109 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $48 | $153 | $259 |
| Screening mammography bilateral CPT 77067 • Imaging | $38 | $66 | $93 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $29 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $384 | $487 | $590 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $6 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $8 | $10 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $9 | $12 |
| Lipid panel CPT 80061 • Laboratory | $9 | $12 | $15 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $7 | $9 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $4 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $4 |