| CT maxillofacial with contrast CPT 70487 • Imaging | $78 | $125 | $171 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $256 | $619 |
| CT angiography neck CPT 70498 • Imaging | $30 | $449 | $1,165 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $444 | $1,271 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $248 | $619 |
| MRI brain with contrast CPT 70552 • Imaging | $30 | $331 | $840 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $201 | $301 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $38 | $55 |
| Chest X-ray 2 views CPT 71046 • Imaging | $15 | $24 | $29 |
| CT chest without contrast CPT 71250 • Imaging | $83 | $113 | $134 |
| CT chest with contrast CPT 71260 • Imaging | $30 | $247 | $603 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $379 | $727 |
| CT angiography chest CPT 71275 • Imaging | $139 | $215 | $255 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $157 | $353 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $111 | $173 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $165 | $350 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $201 | $419 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $208 | $614 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $226 | $615 |
| CT pelvis without contrast CPT 72192 • Imaging | $240 | $240 | $240 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $191 | $440 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $46 | $79 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $141 | $161 | $180 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $49 | $85 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $58 | $86 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $405 | $746 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $179 | $263 | $462 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $135 | $235 |
| CT abdomen with contrast CPT 74160 • Imaging | $88 | $263 | $438 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $364 | $699 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $154 | $189 | $229 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $124 | $247 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $350 | $463 | $687 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $30 | $139 | $251 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $104 | $239 |
| Ultrasound transvaginal CPT 76830 • Imaging | $47 | $157 | $319 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $61 | $75 | $90 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $72 | $99 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $89 | $218 | $427 |
| Screening mammography bilateral CPT 77067 • Imaging | $68 | $135 | $247 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $52 | $135 | $217 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $68 | $523 | $1,524 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $6 | $17 |
| Basic metabolic panel CPT 80048 • Laboratory | $1 | $6 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $12 | $12 | $12 |
| Lipid panel CPT 80061 • Laboratory | $11 | $18 | $24 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $9 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $4 | $6 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $4 | $7 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $3 | $4 |