| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $30 | $30 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $15 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $82 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $84 | $84 | $84 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $51 | $153 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $30 | $30 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $84 | $84 | $84 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $131 | $131 | $131 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $113 | $196 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $39 | $39 | $39 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $30 | $30 |
| CT pelvis without contrast CPT 72192 • Imaging | $30 | $30 | $30 |
| CT pelvis with contrast CPT 72193 • Imaging | $45 | $45 | $45 |
| X-ray shoulder complete CPT 73030 • Imaging | $22 | $26 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $41 | $124 | $206 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $30 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $32 | $32 | $32 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $147 | $229 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $103 | $103 | $103 |
| CT abdomen without contrast CPT 74150 • Imaging | $28 | $83 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $169 | $169 | $169 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $30 | $30 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $83 | $134 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $200 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $95 | $223 | $350 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $41 | $52 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $32 | $64 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $76 | $90 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $19 | $19 | $19 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $76 | $93 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $43 | $91 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $112 | $112 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $32 | $32 | $32 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $195 | $323 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $1 | $1 | $1 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $6 | $8 |
| Lipid panel CPT 80061 • Laboratory | $5 | $5 | $5 |
| Hepatic function panel CPT 80076 • Laboratory | $1 | $1 | $1 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $1 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $1 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $6 | $6 | $6 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $12 | $17 | $23 |
| Creatine kinase (CK) total CPT 82550 • Laboratory | $3 | $3 | $3 |
| Creatinine urine CPT 82570 • Laboratory | $1 | $2 | $4 |
| Ferritin CPT 82728 • Laboratory | $10 | $10 | $11 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $4 | $5 | $7 |