| CT maxillofacial without contrast CPT 70486 • Imaging | $76 | $285 | $494 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $72 | $87 | $101 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $123 | $358 | $593 |
| CT angiography neck CPT 70498 • Imaging | $155 | $419 | $682 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $119 | $155 | $192 |
| MRI brain without contrast CPT 70551 • Imaging | $131 | $337 | $543 |
| MRI brain with contrast CPT 70552 • Imaging | $99 | $99 | $99 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $204 | $429 | $654 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $19 | $22 |
| Chest X-ray 2 views CPT 71046 • Imaging | $18 | $26 | $34 |
| CT chest without contrast CPT 71250 • Imaging | $28 | $46 | $65 |
| CT chest with contrast CPT 71260 • Imaging | $104 | $216 | $328 |
| CT chest without then with contrast CPT 71270 • Imaging | $77 | $77 | $77 |
| CT angiography chest CPT 71275 • Imaging | $156 | $347 | $538 |
| CT cervical spine without contrast CPT 72125 • Imaging | $90 | $150 | $210 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $90 | $150 | $209 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $88 | $338 | $588 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $132 | $313 | $495 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $132 | $318 | $504 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $131 | $273 | $415 |
| CT pelvis without contrast CPT 72192 • Imaging | $96 | $338 | $580 |
| CT pelvis with contrast CPT 72193 • Imaging | $103 | $175 | $246 |
| X-ray shoulder complete CPT 73030 • Imaging | $8 | $23 | $34 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $75 | $75 | $75 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $10 | $20 | $35 |
| X-ray ankle complete CPT 73610 • Imaging | $8 | $17 | $33 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $120 | $289 | $457 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $120 | $283 | $446 |
| CT abdomen without contrast CPT 74150 • Imaging | $65 | $164 | $263 |
| CT abdomen with contrast CPT 74160 • Imaging | $351 | $351 | $351 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $383 | $383 | $383 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $99 | $127 | $155 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $162 | $226 | $289 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $190 | $343 | $496 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $73 | $108 | $144 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $66 | $149 | $236 |
| Ultrasound transvaginal CPT 76830 • Imaging | $67 | $97 | $127 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $38 | $50 | $61 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $44 | $58 | $73 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $55 | $71 | $88 |
| Screening mammography bilateral CPT 77067 • Imaging | $42 | $55 | $68 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $18 | $54 | $90 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $478 | $478 | $478 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $5 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $5 | $8 |
| Lipid panel CPT 80061 • Laboratory | $8 | $17 | $22 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $6 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $4 |