| CT head without then with contrast CPT 70470 • Imaging | $93 | $138 | $183 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $43 | $127 | $275 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $82 | $121 | $160 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $194 | $272 | $346 |
| CT angiography neck CPT 70498 • Imaging | $87 | $163 | $275 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $180 | $425 |
| MRI brain without contrast CPT 70551 • Imaging | $131 | $299 | $425 |
| MRI brain with contrast CPT 70552 • Imaging | $89 | $169 | $296 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $156 | $282 | $425 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $32 | $55 |
| Chest X-ray 2 views CPT 71046 • Imaging | $20 | $29 | $38 |
| CT chest without contrast CPT 71250 • Imaging | $58 | $144 | $275 |
| CT chest with contrast CPT 71260 • Imaging | $85 | $127 | $188 |
| CT chest without then with contrast CPT 71270 • Imaging | $69 | $172 | $275 |
| CT angiography chest CPT 71275 • Imaging | $126 | $200 | $275 |
| CT cervical spine without contrast CPT 72125 • Imaging | $68 | $147 | $275 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $68 | $147 | $275 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $99 | $163 | $275 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $183 | $310 | $425 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $67 | $197 | $425 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $74 | $271 | $425 |
| CT pelvis without contrast CPT 72192 • Imaging | $54 | $67 | $80 |
| CT pelvis with contrast CPT 72193 • Imaging | $58 | $145 | $275 |
| X-ray shoulder complete CPT 73030 • Imaging | $13 | $26 | $32 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $68 | $109 | $132 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $19 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $24 | $30 | $34 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $98 | $236 | $425 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $67 | $151 | $221 |
| CT abdomen without contrast CPT 74150 • Imaging | $87 | $195 | $275 |
| CT abdomen with contrast CPT 74160 • Imaging | $88 | $158 | $228 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $102 | $212 | $275 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $106 | $177 | $275 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $124 | $288 | $439 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $146 | $260 | $344 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $60 | $77 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $67 | $109 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $66 | $118 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $33 | $71 | $146 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $36 | $79 | $120 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $74 | $129 | $162 |
| Screening mammography bilateral CPT 77067 • Imaging | $68 | $126 | $221 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $38 | $45 | $52 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $116 | $290 | $381 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $7 | $17 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $7 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $6 | $8 | $10 |
| Lipid panel CPT 80061 • Laboratory | $4 | $10 | $13 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $8 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $3 | $6 |