| CT maxillofacial without contrast CPT 70486 • Imaging | $50 | $50 | $50 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $291 | $291 | $291 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $228 | $228 | $228 |
| CT angiography neck CPT 70498 • Imaging | $467 | $467 | $467 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $95 | $95 | $95 |
| MRI brain without contrast CPT 70551 • Imaging | $499 | $499 | $499 |
| MRI brain with contrast CPT 70552 • Imaging | $491 | $491 | $491 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $734 | $734 | $734 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $9 | $9 |
| Chest X-ray 2 views CPT 71046 • Imaging | $29 | $29 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $51 | $51 | $51 |
| CT chest with contrast CPT 71260 • Imaging | $308 | $308 | $308 |
| CT chest without then with contrast CPT 71270 • Imaging | $379 | $379 | $379 |
| CT angiography chest CPT 71275 • Imaging | $401 | $401 | $401 |
| CT cervical spine without contrast CPT 72125 • Imaging | $207 | $207 | $207 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $207 | $207 | $207 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $206 | $206 | $206 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $470 | $470 | $470 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $492 | $492 | $492 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $487 | $487 | $487 |
| CT pelvis without contrast CPT 72192 • Imaging | $48 | $48 | $48 |
| CT pelvis with contrast CPT 72193 • Imaging | $242 | $242 | $242 |
| X-ray shoulder complete CPT 73030 • Imaging | $27 | $27 | $27 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $59 | $59 | $59 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $25 | $25 | $25 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $8 | $8 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $427 | $427 | $427 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $420 | $420 | $420 |
| CT abdomen without contrast CPT 74150 • Imaging | $53 | $53 | $53 |
| CT abdomen with contrast CPT 74160 • Imaging | $57 | $57 | $57 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $409 | $409 | $409 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $129 | $129 | $129 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $91 | $91 | $91 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $427 | $427 | $427 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $117 | $117 | $117 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $33 | $33 | $33 |
| Ultrasound transvaginal CPT 76830 • Imaging | $101 | $101 | $101 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $70 | $70 | $70 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $88 | $88 | $88 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $48 | $48 | $48 |
| Screening mammography bilateral CPT 77067 • Imaging | $37 | $37 | $37 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $9 | $9 | $9 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $466 | $466 | $466 |
| 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 | $9 | $9 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |