| CT head without then with contrast CPT 70470 • Imaging | $40 | $63 | $86 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $34 | $48 | $61 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $69 | $77 | $86 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $51 | $67 | $83 |
| CT angiography neck CPT 70498 • Imaging | $34 | $44 | $55 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $67 | $147 | $250 |
| MRI brain without contrast CPT 70551 • Imaging | $135 | $212 | $250 |
| MRI brain with contrast CPT 70552 • Imaging | $125 | $187 | $250 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $147 | $195 | $250 |
| Chest X-ray single view CPT 71045 • Imaging | $6 | $11 | $17 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $18 | $22 |
| CT chest without contrast CPT 71250 • Imaging | $34 | $38 | $45 |
| CT chest with contrast CPT 71260 • Imaging | $51 | $72 | $115 |
| CT chest without then with contrast CPT 71270 • Imaging | $39 | $42 | $45 |
| CT angiography chest CPT 71275 • Imaging | $86 | $131 | $171 |
| CT cervical spine without contrast CPT 72125 • Imaging | $51 | $70 | $89 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $31 | $101 | $171 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $57 | $71 | $86 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $63 | $132 | $250 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $45 | $74 | $131 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $47 | $116 | $250 |
| CT pelvis without contrast CPT 72192 • Imaging | $51 | $54 | $57 |
| CT pelvis with contrast CPT 72193 • Imaging | $34 | $78 | $121 |
| X-ray shoulder complete CPT 73030 • Imaging | $5 | $15 | $23 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $43 | $113 | $250 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $5 | $15 | $23 |
| X-ray ankle complete CPT 73610 • Imaging | $25 | $31 | $45 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $50 | $151 | $250 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $45 | $68 | $97 |
| CT abdomen without contrast CPT 74150 • Imaging | $37 | $126 | $171 |
| CT abdomen with contrast CPT 74160 • Imaging | $45 | $103 | $160 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $44 | $48 | $51 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $51 | $98 | $171 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $171 | $183 | $208 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $120 | $175 | $234 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $16 | $59 | $82 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $24 | $57 | $75 |
| Ultrasound transvaginal CPT 76830 • Imaging | $45 | $69 | $83 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $21 | $39 | $51 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $84 | $107 | $139 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $106 | $152 | $176 |
| Screening mammography bilateral CPT 77067 • Imaging | $38 | $46 | $62 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $20 | $23 | $26 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $51 | $203 | $290 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $0 | $2 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $6 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $4 | $4 |
| Lipid panel CPT 80061 • Laboratory | $6 | $6 | $6 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $4 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $1 | $2 | $2 |