| CT head without then with contrast CPT 70470 • Imaging | $60 | $106 | $152 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $54 | $194 | $346 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $71 | $177 | $282 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $65 | $232 | $542 |
| CT angiography neck CPT 70498 • Imaging | $83 | $228 | $492 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $135 | $493 | $699 |
| MRI brain without contrast CPT 70551 • Imaging | $182 | $469 | $621 |
| MRI brain with contrast CPT 70552 • Imaging | $113 | $452 | $737 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $64 | $365 | $635 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $18 | $28 |
| Chest X-ray 2 views CPT 71046 • Imaging | $16 | $25 | $33 |
| CT chest without contrast CPT 71250 • Imaging | $120 | $274 | $402 |
| CT chest with contrast CPT 71260 • Imaging | $59 | $96 | $150 |
| CT chest without then with contrast CPT 71270 • Imaging | $87 | $294 | $461 |
| CT angiography chest CPT 71275 • Imaging | $91 | $299 | $692 |
| CT cervical spine without contrast CPT 72125 • Imaging | $68 | $212 | $346 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $63 | $210 | $346 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $63 | $210 | $346 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $76 | $373 | $621 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $64 | $256 | $534 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $94 | $413 | $621 |
| CT pelvis without contrast CPT 72192 • Imaging | $69 | $115 | $162 |
| CT pelvis with contrast CPT 72193 • Imaging | $55 | $216 | $519 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $36 | $67 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $164 | $240 | $360 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $24 | $45 | $71 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $33 | $72 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $85 | $398 | $669 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $64 | $285 | $621 |
| CT abdomen without contrast CPT 74150 • Imaging | $56 | $220 | $402 |
| CT abdomen with contrast CPT 74160 • Imaging | $60 | $70 | $80 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $88 | $285 | $440 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $132 | $244 | $466 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $272 | $510 | $717 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $264 | $579 | $814 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $97 | $172 | $284 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $35 | $145 | $263 |
| Ultrasound transvaginal CPT 76830 • Imaging | $88 | $166 | $284 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $44 | $81 | $120 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $51 | $152 | $224 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $63 | $202 | $389 |
| Screening mammography bilateral CPT 77067 • Imaging | $118 | $196 | $314 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $36 | $45 | $53 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $115 | $477 | $815 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $4 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $6 | $16 | $27 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $11 | $15 |
| Lipid panel CPT 80061 • Laboratory | $9 | $20 | $32 |
| Hepatic function panel CPT 80076 • Laboratory | $6 | $16 | $27 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $6 | $10 |