| CT maxillofacial without contrast CPT 70486 • Imaging | $95 | $104 | $113 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $90 | $90 | $90 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $165 | $176 | $187 |
| CT angiography neck CPT 70498 • Imaging | $72 | $175 | $279 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $316 | $316 | $316 |
| MRI brain without contrast CPT 70551 • Imaging | $120 | $160 | $199 |
| MRI brain with contrast CPT 70552 • Imaging | $251 | $251 | $251 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $297 | $308 | $319 |
| Chest X-ray single view CPT 71045 • Imaging | $7 | $7 | $8 |
| Chest X-ray 2 views CPT 71046 • Imaging | $14 | $18 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $83 | $128 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $100 | $159 |
| CT chest without then with contrast CPT 71270 • Imaging | $56 | $56 | $56 |
| CT angiography chest CPT 71275 • Imaging | $64 | $69 | $74 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $81 | $126 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $38 | $41 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $38 | $41 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $115 | $155 | $195 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $115 | $115 | $115 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $71 | $124 | $177 |
| CT pelvis without contrast CPT 72192 • Imaging | $44 | $48 | $51 |
| CT pelvis with contrast CPT 72193 • Imaging | $47 | $47 | $47 |
| X-ray shoulder complete CPT 73030 • Imaging | $16 | $30 | $40 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $56 | $81 | $106 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $7 | $24 | $40 |
| X-ray ankle complete CPT 73610 • Imaging | $21 | $29 | $38 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $154 | $190 | $226 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $186 | $197 | $208 |
| CT abdomen without contrast CPT 74150 • Imaging | $49 | $94 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $149 | $149 | $149 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $145 | $186 | $227 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $163 | $175 | $187 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $266 | $286 | $305 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $217 | $280 | $344 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $84 | $92 | $100 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $52 | $72 | $92 |
| Ultrasound transvaginal CPT 76830 • Imaging | $30 | $73 | $100 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $89 | $98 | $107 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $33 | $80 | $126 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $96 | $106 | $115 |
| Screening mammography bilateral CPT 77067 • Imaging | $31 | $63 | $95 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $30 | $32 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $354 | $388 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $4 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $4 | $4 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $6 | $10 |
| Lipid panel CPT 80061 • Laboratory | $3 | $7 | $12 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $3 | $3 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $2 |