| CT maxillofacial without contrast CPT 70486 • Imaging | $201 | $201 | $201 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $61 | $61 | $61 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $240 | $240 | $240 |
| CT angiography neck CPT 70498 • Imaging | $574 | $574 | $574 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $874 | $874 | $874 |
| MRI brain without contrast CPT 70551 • Imaging | $456 | $456 | $456 |
| MRI brain with contrast CPT 70552 • Imaging | $600 | $600 | $600 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $773 | $773 | $773 |
| Chest X-ray single view CPT 71045 • Imaging | $20 | $20 | $20 |
| Chest X-ray 2 views CPT 71046 • Imaging | $31 | $31 | $31 |
| CT chest without contrast CPT 71250 • Imaging | $271 | $271 | $271 |
| CT chest with contrast CPT 71260 • Imaging | $324 | $324 | $324 |
| CT chest without then with contrast CPT 71270 • Imaging | $335 | $335 | $335 |
| CT angiography chest CPT 71275 • Imaging | $422 | $422 | $422 |
| CT cervical spine without contrast CPT 72125 • Imaging | $54 | $54 | $54 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $218 | $218 | $218 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $54 | $54 | $54 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $74 | $74 | $74 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $74 | $74 | $74 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $444 | $444 | $444 |
| CT pelvis without contrast CPT 72192 • Imaging | $211 | $211 | $211 |
| CT pelvis with contrast CPT 72193 • Imaging | $309 | $309 | $309 |
| X-ray shoulder complete CPT 73030 • Imaging | $20 | $20 | $20 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $499 | $499 | $499 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $8 | $8 |
| X-ray ankle complete CPT 73610 • Imaging | $21 | $21 | $21 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $512 | $512 | $512 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $442 | $442 | $442 |
| CT abdomen without contrast CPT 74150 • Imaging | $56 | $56 | $56 |
| CT abdomen with contrast CPT 74160 • Imaging | $60 | $60 | $60 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $365 | $365 | $365 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $228 | $228 | $228 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $96 | $96 | $96 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $106 | $106 | $106 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $86 | $86 | $86 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $118 | $118 | $118 |
| Ultrasound transvaginal CPT 76830 • Imaging | $32 | $32 | $32 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $32 | $32 | $32 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $134 | $134 | $134 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $170 | $170 | $170 |
| Screening mammography bilateral CPT 77067 • Imaging | $98 | $98 | $98 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $87 | $87 | $87 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $490 | $490 | $490 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $2 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $9 | $9 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |