| CT maxillofacial without contrast CPT 70486 • Imaging | $48 | $125 | $171 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $66 | $66 | $66 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $36 | $107 | $205 |
| CT angiography neck CPT 70498 • Imaging | $98 | $262 | $385 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $999 | $999 | $999 |
| MRI brain without contrast CPT 70551 • Imaging | $75 | $160 | $240 |
| MRI brain with contrast CPT 70552 • Imaging | $90 | $90 | $90 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $130 | $418 | $1,021 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $17 | $27 |
| Chest X-ray 2 views CPT 71046 • Imaging | $11 | $21 | $27 |
| CT chest without contrast CPT 71250 • Imaging | $62 | $165 | $273 |
| CT chest with contrast CPT 71260 • Imaging | $36 | $55 | $66 |
| CT chest without then with contrast CPT 71270 • Imaging | $240 | $315 | $390 |
| CT angiography chest CPT 71275 • Imaging | $103 | $284 | $442 |
| CT cervical spine without contrast CPT 72125 • Imaging | $56 | $162 | $273 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $56 | $91 | $158 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $56 | $143 | $214 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $235 | $292 | $406 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $234 | $307 | $451 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $36 | $202 | $451 |
| CT pelvis without contrast CPT 72192 • Imaging | $214 | $214 | $214 |
| CT pelvis with contrast CPT 72193 • Imaging | $66 | $194 | $269 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $10 | $11 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $248 | $358 | $469 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $27 | $33 | $36 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $19 | $29 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $76 | $273 | $469 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $169 | $295 | $469 |
| CT abdomen without contrast CPT 74150 • Imaging | $167 | $200 | $265 |
| CT abdomen with contrast CPT 74160 • Imaging | $312 | $312 | $312 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $283 | $330 | $378 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $91 | $104 | $124 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $103 | $278 | $376 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $106 | $316 | $421 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $41 | $83 | $124 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $77 | $115 |
| Ultrasound transvaginal CPT 76830 • Imaging | $90 | $109 | $127 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $35 | $37 | $40 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $41 | $55 | $91 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $56 | $131 | $169 |
| Screening mammography bilateral CPT 77067 • Imaging | $38 | $78 | $135 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $11 | $56 | $101 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $138 | $359 | $469 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $3 |
| 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 |