| CT maxillofacial without contrast CPT 70486 • Imaging | $35 | $56 | $76 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $78 | $168 | $258 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $56 | $88 | $120 |
| CT angiography neck CPT 70498 • Imaging | $152 | $202 | $252 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $86 | $86 | $86 |
| MRI brain without contrast CPT 70551 • Imaging | $191 | $367 | $543 |
| MRI brain with contrast CPT 70552 • Imaging | $121 | $192 | $262 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $156 | $186 | $216 |
| Chest X-ray single view CPT 71045 • Imaging | $12 | $20 | $29 |
| Chest X-ray 2 views CPT 71046 • Imaging | $21 | $28 | $36 |
| CT chest without contrast CPT 71250 • Imaging | $100 | $117 | $133 |
| CT chest with contrast CPT 71260 • Imaging | $108 | $137 | $166 |
| CT chest without then with contrast CPT 71270 • Imaging | $141 | $141 | $141 |
| CT angiography chest CPT 71275 • Imaging | $107 | $116 | $126 |
| CT cervical spine without contrast CPT 72125 • Imaging | $41 | $54 | $68 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $132 | $152 | $173 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $41 | $78 | $114 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $61 | $122 | $183 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $123 | $155 | $187 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $83 | $135 | $187 |
| CT pelvis without contrast CPT 72192 • Imaging | $259 | $259 | $259 |
| CT pelvis with contrast CPT 72193 • Imaging | $102 | $131 | $159 |
| X-ray shoulder complete CPT 73030 • Imaging | $27 | $46 | $66 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $139 | $139 | $139 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $10 | $47 | $85 |
| X-ray ankle complete CPT 73610 • Imaging | $33 | $39 | $46 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $164 | $164 | $164 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $179 | $187 | $194 |
| CT abdomen without contrast CPT 74150 • Imaging | $77 | $77 | $77 |
| CT abdomen with contrast CPT 74160 • Imaging | $88 | $149 | $210 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $383 | $383 | $383 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $97 | $126 | $154 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $124 | $258 | $392 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $312 | $312 | $312 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $67 | $70 | $72 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $63 | $81 | $100 |
| Ultrasound transvaginal CPT 76830 • Imaging | $34 | $114 | $164 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $88 | $117 | $146 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $72 | $76 | $81 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $89 | $163 | $238 |
| Screening mammography bilateral CPT 77067 • Imaging | $68 | $92 | $117 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $11 | $32 | $52 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $50 | $342 | $631 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $1 | $7 | $17 |
| Basic metabolic panel CPT 80048 • Laboratory | $3 | $3 | $3 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $3 | $3 |
| Lipid panel CPT 80061 • Laboratory | $4 | $14 | $24 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $6 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $4 | $6 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $4 | $6 |