| CT head without then with contrast CPT 70470 • Imaging | $86 | $207 | $328 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $74 | $187 | $275 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $99 | $214 | $330 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $121 | $240 | $325 |
| CT angiography neck CPT 70498 • Imaging | $152 | $370 | $682 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $187 | $396 | $672 |
| MRI brain without contrast CPT 70551 • Imaging | $191 | $375 | $461 |
| MRI brain with contrast CPT 70552 • Imaging | $121 | $314 | $508 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $131 | $279 | $425 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $15 | $18 |
| Chest X-ray 2 views CPT 71046 • Imaging | $21 | $29 | $37 |
| CT chest without contrast CPT 71250 • Imaging | $131 | $239 | $275 |
| CT chest with contrast CPT 71260 • Imaging | $69 | $74 | $83 |
| CT chest without then with contrast CPT 71270 • Imaging | $275 | $339 | $404 |
| CT angiography chest CPT 71275 • Imaging | $80 | $297 | $538 |
| CT cervical spine without contrast CPT 72125 • Imaging | $93 | $214 | $275 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $173 | $241 | $275 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $65 | $142 | $275 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $183 | $382 | $495 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $159 | $325 | $425 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $129 | $369 | $498 |
| CT pelvis without contrast CPT 72192 • Imaging | $61 | $78 | $95 |
| CT pelvis with contrast CPT 72193 • Imaging | $80 | $222 | $311 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $30 | $31 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $30 | $195 | $437 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $21 | $27 | $33 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $25 | $59 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $75 | $206 | $425 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $118 | $354 | $446 |
| CT abdomen without contrast CPT 74150 • Imaging | $103 | $229 | $275 |
| CT abdomen with contrast CPT 74160 • Imaging | $88 | $184 | $280 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $78 | $158 | $275 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $154 | $226 | $275 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $126 | $241 | $289 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $114 | $210 | $275 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $77 | $131 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $62 | $100 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $43 | $61 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $52 | $76 | $116 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $56 | $90 | $120 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $70 | $100 | $152 |
| Screening mammography bilateral CPT 77067 • Imaging | $34 | $102 | $192 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $39 | $60 | $82 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $87 | $205 | $332 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $8 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $9 | $12 |
| Lipid panel CPT 80061 • Laboratory | $10 | $14 | $19 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $8 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $5 |