| CT head without then with contrast CPT 70470 • Imaging | $292 | $292 | $292 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $229 | $229 | $229 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $221 | $221 | $221 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $188 | $231 | $274 |
| CT angiography neck CPT 70498 • Imaging | $443 | $443 | $443 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $348 | $567 | $787 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $256 | $472 |
| MRI brain with contrast CPT 70552 • Imaging | $540 | $540 | $540 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $794 | $794 | $794 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $18 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $10 | $10 |
| CT chest without contrast CPT 71250 • Imaging | $134 | $171 | $244 |
| CT chest with contrast CPT 71260 • Imaging | $240 | $240 | $240 |
| CT chest without then with contrast CPT 71270 • Imaging | $200 | $251 | $301 |
| CT angiography chest CPT 71275 • Imaging | $460 | $460 | $460 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $48 | $48 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $244 | $244 | $244 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $244 | $244 | $244 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $196 | $321 | $445 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $195 | $331 | $466 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $62 | $62 | $62 |
| CT pelvis without contrast CPT 72192 • Imaging | $46 | $46 | $46 |
| CT pelvis with contrast CPT 72193 • Imaging | $224 | $251 | $278 |
| X-ray shoulder complete CPT 73030 • Imaging | $8 | $23 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $56 | $56 | $56 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $17 | $23 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $6 | $7 | $7 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $56 | $56 | $56 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $206 | $302 | $398 |
| CT abdomen without contrast CPT 74150 • Imaging | $50 | $50 | $50 |
| CT abdomen with contrast CPT 74160 • Imaging | $249 | $249 | $249 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $387 | $387 | $387 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $185 | $195 | $205 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $86 | $238 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $369 | $405 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $77 | $90 | $103 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $31 | $31 | $31 |
| Ultrasound transvaginal CPT 76830 • Imaging | $29 | $67 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $29 | $62 | $96 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $37 | $86 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $46 | $92 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $93 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $69 | $69 | $69 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $322 | $382 | $441 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $5 | $7 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |