| MRI thoracic spine without contrast CPT 72146 • Imaging | $71 | $71 | $71 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $191 | $191 | $191 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $52 | $52 |
| CT pelvis with contrast CPT 72193 • Imaging | $56 | $56 | $56 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $23 | $23 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $209 | $209 | $209 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $25 | $25 | $25 |
| X-ray ankle complete CPT 73610 • Imaging | $24 | $24 | $24 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $64 | $64 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $203 | $203 | $203 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $57 | $57 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $67 | $67 | $67 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $84 | $84 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $87 | $87 | $87 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $97 | $97 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $116 | $116 | $116 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $78 | $78 | $78 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $33 | $33 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $76 | $76 | $76 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $126 | $126 | $126 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $156 | $156 | $156 |
| Screening mammography bilateral CPT 77067 • Imaging | $128 | $128 | $128 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $40 | $40 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $319 | $319 | $319 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $3 | $3 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $5 | $5 |
| Lipid panel CPT 80061 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $1 | $1 |
| Vitamin D 25-hydroxy CPT 82306 • Laboratory | $7 | $7 | $7 |
| Creatinine urine CPT 82570 • Laboratory | $2 | $2 | $2 |
| Ferritin CPT 82728 • Laboratory | $7 | $7 | $7 |
| IgA IgD IgG IgM each CPT 82784 • Laboratory | $5 | $5 | $5 |
| Glucose quantitative blood CPT 82947 • Laboratory | $2 | $2 | $2 |
| Hemoglobin A1c CPT 83036 • Laboratory | $4 | $4 | $4 |
| Iron serum CPT 83540 • Laboratory | $3 | $3 | $3 |
| Iron binding capacity CPT 83550 • Laboratory | $4 | $4 | $4 |
| Prostate specific antigen (PSA) CPT 84153 • Laboratory | $8 | $8 | $8 |
| Free thyroxine (T4) CPT 84439 • Laboratory | $4 | $4 | $4 |
| Thyroid stimulating hormone (TSH) CPT 84443 • Laboratory | $4 | $4 | $4 |
| Complete blood count with differential CPT 85025 • Laboratory | $3 | $3 | $3 |
| Complete blood count automated CPT 85027 • Laboratory | $3 | $3 | $3 |
| Prothrombin time (PT) CPT 85610 • Laboratory | $2 | $2 | $2 |
| TB skin test intradermal CPT 86580 • Laboratory | $4 | $4 | $4 |
| Chlamydia nucleic acid amplification CPT 87491 • Laboratory | $18 | $18 | $18 |
| Gonorrhea nucleic acid amplification CPT 87591 • Laboratory | $13 | $13 | $13 |
| SARS-CoV-2 COVID-19 amplified probe CPT 87635 • Laboratory | $22 | $22 | $22 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $8 | $8 | $8 |
| Strep A assay with optic observation CPT 87880 • Laboratory | $8 | $8 | $8 |