| CT maxillofacial without contrast CPT 70486 • Imaging | $48 | $87 | $155 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $176 | $176 | $176 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $36 | $65 | $81 |
| CT angiography neck CPT 70498 • Imaging | $98 | $347 | $641 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $66 | $66 | $66 |
| MRI brain without contrast CPT 70551 • Imaging | $46 | $156 | $240 |
| MRI brain with contrast CPT 70552 • Imaging | $176 | $176 | $176 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $130 | $234 | $392 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $16 | $27 |
| Chest X-ray 2 views CPT 71046 • Imaging | $7 | $18 | $35 |
| CT chest without contrast CPT 71250 • Imaging | $129 | $155 | $169 |
| CT chest with contrast CPT 71260 • Imaging | $36 | $95 | $182 |
| CT chest without then with contrast CPT 71270 • Imaging | $240 | $446 | $652 |
| CT angiography chest CPT 71275 • Imaging | $56 | $155 | $307 |
| CT cervical spine without contrast CPT 72125 • Imaging | $31 | $82 | $158 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $56 | $103 | $158 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $56 | $92 | $157 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $87 | $185 | $235 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $234 | $575 | $1,257 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $133 | $460 | $1,238 |
| CT pelvis without contrast CPT 72192 • Imaging | $442 | $442 | $442 |
| CT pelvis with contrast CPT 72193 • Imaging | $66 | $149 | $269 |
| X-ray shoulder complete CPT 73030 • Imaging | $10 | $25 | $37 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $78 | $206 | $370 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $32 | $46 | $69 |
| X-ray ankle complete CPT 73610 • Imaging | $5 | $28 | $44 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $76 | $602 | $1,454 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $90 | $215 | $379 |
| CT abdomen without contrast CPT 74150 • Imaging | $167 | $173 | $185 |
| CT abdomen with contrast CPT 74160 • Imaging | $151 | $151 | $151 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $124 | $427 | $874 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $124 | $218 | $337 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $103 | $396 | $730 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $312 | $386 | $421 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $79 | $98 | $124 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $72 | $97 | $115 |
| Ultrasound transvaginal CPT 76830 • Imaging | $21 | $105 | $166 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $36 | $41 | $46 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $47 | $135 | $268 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $56 | $109 | $167 |
| Screening mammography bilateral CPT 77067 • Imaging | $39 | $123 | $238 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $24 | $40 | $56 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $49 | $329 | $469 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $7 | $19 |
| Basic metabolic panel CPT 80048 • Laboratory | $8 | $9 | $9 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $6 | $6 |
| Lipid panel CPT 80061 • Laboratory | $8 | $16 | $27 |
| Hepatic function panel CPT 80076 • Laboratory | $8 | $8 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $4 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $4 |