| CT maxillofacial without contrast CPT 70486 • Imaging | $50 | $229 | $408 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $184 | $184 | $184 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $178 | $344 | $510 |
| CT angiography neck CPT 70498 • Imaging | $102 | $102 | $102 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $108 | $220 | $331 |
| MRI brain without contrast CPT 70551 • Imaging | $207 | $231 | $254 |
| MRI brain with contrast CPT 70552 • Imaging | $247 | $266 | $285 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $281 | $309 | $336 |
| Chest X-ray single view CPT 71045 • Imaging | $8 | $15 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $25 | $29 | $34 |
| CT chest without contrast CPT 71250 • Imaging | $139 | $319 | $409 |
| CT chest with contrast CPT 71260 • Imaging | $57 | $154 | $251 |
| CT chest without then with contrast CPT 71270 • Imaging | $221 | $412 | $604 |
| CT angiography chest CPT 71275 • Imaging | $106 | $380 | $654 |
| CT cervical spine without contrast CPT 72125 • Imaging | $141 | $275 | $409 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $198 | $198 | $198 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $197 | $197 | $197 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $161 | $181 | $202 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $28 | $274 | $707 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $246 | $547 | $697 |
| CT pelvis without contrast CPT 72192 • Imaging | $161 | $161 | $161 |
| CT pelvis with contrast CPT 72193 • Imaging | $180 | $180 | $180 |
| X-ray shoulder complete CPT 73030 • Imaging | $32 | $45 | $52 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $69 | $74 | $79 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $24 | $40 | $48 |
| X-ray ankle complete CPT 73610 • Imaging | $10 | $37 | $50 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $235 | $316 | $397 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $79 | $112 | $145 |
| CT abdomen without contrast CPT 74150 • Imaging | $69 | $105 | $140 |
| CT abdomen with contrast CPT 74160 • Imaging | $179 | $179 | $179 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $206 | $406 | $607 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $103 | $112 | $122 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $313 | $323 | $341 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $347 | $367 | $387 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $135 | $172 | $208 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $83 | $93 | $103 |
| Ultrasound transvaginal CPT 76830 • Imaging | $95 | $134 | $173 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $32 | $36 | $40 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $101 | $107 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $129 | $134 | $139 |
| Screening mammography bilateral CPT 77067 • Imaging | $43 | $97 | $126 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $8 | $8 | $8 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $407 | $440 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $5 | $6 | $7 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $15 | $20 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $7 | $8 |
| Lipid panel CPT 80061 • Laboratory | $7 | $25 | $34 |
| Hepatic function panel CPT 80076 • Laboratory | $4 | $5 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $6 | $8 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $4 | $6 |