| CT head without then with contrast CPT 70470 • Imaging | $65 | $76 | $87 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $27 | $27 | $28 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $75 | $91 | $107 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $126 | $159 | $192 |
| CT angiography neck CPT 70498 • Imaging | $169 | $185 | $202 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $67 | $194 | $322 |
| MRI brain without contrast CPT 70551 • Imaging | $74 | $126 | $200 |
| MRI brain with contrast CPT 70552 • Imaging | $276 | $363 | $510 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $79 | $121 | $163 |
| Chest X-ray single view CPT 71045 • Imaging | $10 | $13 | $15 |
| Chest X-ray 2 views CPT 71046 • Imaging | $19 | $22 | $25 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $75 | $120 |
| CT chest with contrast CPT 71260 • Imaging | $34 | $68 | $115 |
| CT chest without then with contrast CPT 71270 • Imaging | $44 | $77 | $111 |
| CT angiography chest CPT 71275 • Imaging | $38 | $166 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $54 | $63 | $72 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $51 | $72 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $57 | $94 | $131 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $51 | $91 | $124 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $70 | $135 | $237 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $74 | $118 | $156 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $75 | $99 |
| CT pelvis with contrast CPT 72193 • Imaging | $40 | $46 | $53 |
| X-ray shoulder complete CPT 73030 • Imaging | $7 | $22 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $68 | $214 | $369 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $5 | $18 | $29 |
| X-ray ankle complete CPT 73610 • Imaging | $6 | $10 | $16 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $85 | $107 | $129 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $43 | $146 | $206 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $86 | $139 |
| CT abdomen with contrast CPT 74160 • Imaging | $63 | $116 | $169 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $47 | $48 | $48 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $76 | $121 | $185 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $205 | $280 | $323 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $100 | $236 | $350 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $103 | $108 | $117 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $25 | $60 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $22 | $50 | $105 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $21 | $34 | $47 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $34 | $52 | $88 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $43 | $114 | $161 |
| Screening mammography bilateral CPT 77067 • Imaging | $32 | $43 | $62 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $24 | $25 | $26 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $179 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $5 | $6 | $8 |
| Lipid panel CPT 80061 • Laboratory | $9 | $10 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $7 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $2 |