| CT head with contrast CPT 70460 • Imaging | $30 | $30 | $30 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $35 | $41 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $54 | $54 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $201 | $335 |
| CT angiography neck CPT 70498 • Imaging | $30 | $57 | $83 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $66 | $103 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $146 | $200 |
| MRI brain with contrast CPT 70552 • Imaging | $475 | $475 | $475 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $70 | $110 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $17 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $25 | $27 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $115 | $264 |
| CT chest with contrast CPT 71260 • Imaging | $56 | $85 | $113 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $30 | $30 |
| CT angiography chest CPT 71275 • Imaging | $87 | $277 | $467 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $33 | $35 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $39 | $49 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $33 | $35 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $71 | $261 | $475 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $112 | $194 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $132 | $196 |
| CT pelvis without contrast CPT 72192 • Imaging | $62 | $62 | $62 |
| CT pelvis with contrast CPT 72193 • Imaging | $55 | $187 | $318 |
| X-ray shoulder complete CPT 73030 • Imaging | $17 | $26 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $66 | $66 | $66 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $20 | $26 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $22 | $37 | $56 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $65 | $65 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $66 | $170 | $238 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $75 | $139 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $147 | $263 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $77 | $131 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $226 | $320 | $367 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $341 | $464 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $84 | $116 | $147 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $68 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $86 | $95 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $33 | $84 | $135 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $97 | $143 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $127 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $101 | $120 | $146 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $40 | $40 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $86 | $306 | $513 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $8 | $10 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $5 | $11 | $17 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $8 | $10 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $3 | $4 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $3 |