| CT head without then with contrast CPT 70470 • Imaging | $116 | $225 | $334 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $26 | $142 | $257 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $55 | $172 | $290 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $189 | $365 | $542 |
| CT angiography neck CPT 70498 • Imaging | $256 | $532 | $808 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $103 | $199 | $250 |
| MRI brain without contrast CPT 70551 • Imaging | $101 | $158 | $201 |
| MRI brain with contrast CPT 70552 • Imaging | $192 | $226 | $277 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $66 | $166 | $267 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $28 | $53 |
| Chest X-ray 2 views CPT 71046 • Imaging | $20 | $40 | $69 |
| CT chest without contrast CPT 71250 • Imaging | $84 | $204 | $390 |
| CT chest with contrast CPT 71260 • Imaging | $56 | $272 | $488 |
| CT chest without then with contrast CPT 71270 • Imaging | $100 | $252 | $404 |
| CT angiography chest CPT 71275 • Imaging | $52 | $295 | $574 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $146 | $243 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $133 | $135 | $137 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $84 | $231 | $378 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $173 | $188 | $196 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $124 | $299 | $474 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $125 | $208 | $303 |
| CT pelvis without contrast CPT 72192 • Imaging | $68 | $109 | $150 |
| CT pelvis with contrast CPT 72193 • Imaging | $228 | $452 | $675 |
| X-ray shoulder complete CPT 73030 • Imaging | $23 | $41 | $70 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $42 | $193 | $345 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $6 | $18 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $17 | $37 | $57 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $46 | $225 | $400 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $41 | $88 | $158 |
| CT abdomen without contrast CPT 74150 • Imaging | $140 | $148 | $164 |
| CT abdomen with contrast CPT 74160 • Imaging | $47 | $280 | $513 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $192 | $216 | $240 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $104 | $196 | $298 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $88 | $348 | $645 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $391 | $727 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $53 | $126 | $220 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $49 | $83 | $101 |
| Ultrasound transvaginal CPT 76830 • Imaging | $22 | $75 | $108 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $19 | $159 | $300 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $35 | $75 | $111 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $99 | $126 | $142 |
| Screening mammography bilateral CPT 77067 • Imaging | $33 | $124 | $257 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $9 | $38 | $67 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $70 | $467 | $1,009 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $1 | $5 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $2 | $6 | $11 |
| Lipid panel CPT 80061 • Laboratory | $5 | $9 | $13 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $7 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |