| CT maxillofacial without contrast CPT 70486 • Imaging | $43 | $66 | $89 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $104 | $104 | $104 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $69 | $189 | $308 |
| CT angiography neck CPT 70498 • Imaging | $87 | $170 | $252 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $379 | $379 | $379 |
| MRI brain without contrast CPT 70551 • Imaging | $143 | $143 | $143 |
| MRI brain with contrast CPT 70552 • Imaging | $301 | $301 | $301 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $241 | $241 | $241 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $25 | $39 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $13 | $20 |
| CT chest without contrast CPT 71250 • Imaging | $58 | $158 | $221 |
| CT chest with contrast CPT 71260 • Imaging | $169 | $212 | $278 |
| CT chest without then with contrast CPT 71270 • Imaging | $154 | $154 | $154 |
| CT angiography chest CPT 71275 • Imaging | $169 | $209 | $289 |
| CT cervical spine without contrast CPT 72125 • Imaging | $48 | $112 | $176 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $50 | $50 | $50 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $83 | $128 | $172 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $137 | $137 | $137 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $212 | $212 | $212 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $212 | $212 | $212 |
| CT pelvis without contrast CPT 72192 • Imaging | $85 | $85 | $85 |
| CT pelvis with contrast CPT 72193 • Imaging | $58 | $58 | $58 |
| X-ray shoulder complete CPT 73030 • Imaging | $9 | $37 | $52 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $223 | $223 | $223 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $7 | $30 | $52 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $25 | $56 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $183 | $183 | $183 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $223 | $223 | $223 |
| CT abdomen without contrast CPT 74150 • Imaging | $84 | $84 | $84 |
| CT abdomen with contrast CPT 74160 • Imaging | $63 | $63 | $63 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $70 | $119 | $169 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $87 | $232 | $304 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $214 | $436 | $510 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $245 | $490 | $572 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $76 | $151 | $188 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $37 | $92 | $117 |
| Ultrasound transvaginal CPT 76830 • Imaging | $82 | $155 | $191 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $124 | $169 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $41 | $41 | $41 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $50 | $184 | $250 |
| Screening mammography bilateral CPT 77067 • Imaging | $80 | $122 | $202 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $10 | $10 | $10 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $381 | $557 | $728 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $13 | $17 |
| Lipid panel CPT 80061 • Laboratory | $7 | $13 | $21 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $9 | $13 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $5 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $4 | $6 |