| CT head without then with contrast CPT 70470 • Imaging | $86 | $124 | $167 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $76 | $206 | $372 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $34 | $248 | $631 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $51 | $263 | $619 |
| CT angiography neck CPT 70498 • Imaging | $86 | $391 | $936 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $125 | $698 | $1,271 |
| MRI brain without contrast CPT 70551 • Imaging | $50 | $271 | $619 |
| MRI brain with contrast CPT 70552 • Imaging | $121 | $275 | $605 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $62 | $259 | $692 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $28 | $54 |
| Chest X-ray 2 views CPT 71046 • Imaging | $7 | $34 | $77 |
| CT chest without contrast CPT 71250 • Imaging | $34 | $164 | $349 |
| CT chest with contrast CPT 71260 • Imaging | $45 | $213 | $603 |
| CT chest without then with contrast CPT 71270 • Imaging | $45 | $386 | $727 |
| CT angiography chest CPT 71275 • Imaging | $34 | $146 | $252 |
| CT cervical spine without contrast CPT 72125 • Imaging | $51 | $164 | $353 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $51 | $192 | $351 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $114 | $255 | $481 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $50 | $164 | $250 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $45 | $251 | $614 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $50 | $171 | $250 |
| CT pelvis without contrast CPT 72192 • Imaging | $45 | $214 | $383 |
| CT pelvis with contrast CPT 72193 • Imaging | $34 | $192 | $440 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $38 | $56 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $63 | $121 | $180 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $11 | $25 | $54 |
| X-ray ankle complete CPT 73610 • Imaging | $5 | $32 | $63 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $45 | $339 | $923 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $62 | $152 | $188 |
| CT abdomen without contrast CPT 74150 • Imaging | $157 | $166 | $171 |
| CT abdomen with contrast CPT 74160 • Imaging | $34 | $243 | $605 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $34 | $366 | $699 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $154 | $261 | $550 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $51 | $240 | $579 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $51 | $162 | $264 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $16 | $121 | $251 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $52 | $141 | $336 |
| Ultrasound transvaginal CPT 76830 • Imaging | $61 | $134 | $229 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $23 | $90 | $224 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $72 | $146 | $234 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $51 | $111 | $175 |
| Screening mammography bilateral CPT 77067 • Imaging | $38 | $122 | $344 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $17 | $28 | $47 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $51 | $423 | $1,263 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $0 | $5 | $11 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $8 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $8 | $12 |
| Lipid panel CPT 80061 • Laboratory | $2 | $14 | $24 |
| Hepatic function panel CPT 80076 • Laboratory | $1 | $6 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $3 | $6 |