| CT head with contrast CPT 70460 • Imaging | $30 | $64 | $98 |
| CT head without then with contrast CPT 70470 • Imaging | $63 | $63 | $63 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $36 | $42 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $56 | $56 | $56 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $49 | $69 |
| CT angiography neck CPT 70498 • Imaging | $30 | $58 | $87 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $176 | $323 |
| MRI brain without contrast CPT 70551 • Imaging | $145 | $177 | $188 |
| MRI brain with contrast CPT 70552 • Imaging | $215 | $243 | $257 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $152 | $304 |
| Chest X-ray single view CPT 71045 • Imaging | $9 | $19 | $23 |
| Chest X-ray 2 views CPT 71046 • Imaging | $8 | $16 | $30 |
| CT chest without contrast CPT 71250 • Imaging | $120 | $125 | $126 |
| CT chest with contrast CPT 71260 • Imaging | $155 | $157 | $158 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $111 | $192 |
| CT angiography chest CPT 71275 • Imaging | $194 | $225 | $241 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $42 | $53 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $100 | $171 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $40 | $50 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $74 | $155 | $182 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $95 | $182 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $39 | $119 | $182 |
| CT pelvis without contrast CPT 72192 • Imaging | $139 | $139 | $139 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $44 | $58 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $25 | $31 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $30 | $149 | $224 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $30 | $31 |
| X-ray ankle complete CPT 73610 • Imaging | $9 | $25 | $33 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $207 | $344 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $68 | $165 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $108 | $143 |
| CT abdomen with contrast CPT 74160 • Imaging | $155 | $155 | $155 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $50 | $70 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $175 | $181 | $192 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $91 | $245 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $275 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $40 | $85 | $107 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $66 | $99 |
| Ultrasound transvaginal CPT 76830 • Imaging | $34 | $84 | $109 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $71 | $87 | $97 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $110 | $116 | $127 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $144 | $150 | $161 |
| Screening mammography bilateral CPT 77067 • Imaging | $79 | $100 | $117 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $39 | $39 | $39 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $309 | $394 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $1 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $9 | $10 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |