| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $83 | $136 |
| CT angiography neck CPT 70498 • Imaging | $30 | $62 | $94 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $152 | $312 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $136 | $231 |
| MRI brain with contrast CPT 70552 • Imaging | $96 | $197 | $299 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $199 | $312 |
| Chest X-ray single view CPT 71045 • Imaging | $23 | $25 | $27 |
| Chest X-ray 2 views CPT 71046 • Imaging | $12 | $24 | $36 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $66 | $102 |
| CT chest with contrast CPT 71260 • Imaging | $67 | $112 | $157 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $52 | $74 |
| CT angiography chest CPT 71275 • Imaging | $98 | $127 | $157 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $96 | $161 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $96 | $161 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $68 | $107 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $87 | $145 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $87 | $145 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $101 | $194 |
| CT pelvis without contrast CPT 72192 • Imaging | $92 | $92 | $92 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $140 | $250 |
| X-ray shoulder complete CPT 73030 • Imaging | $24 | $27 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $238 | $238 | $238 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $9 | $20 | $30 |
| X-ray ankle complete CPT 73610 • Imaging | $26 | $28 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $193 | $202 | $211 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $164 | $194 | $211 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $92 | $155 |
| CT abdomen with contrast CPT 74160 • Imaging | $255 | $255 | $255 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $159 | $288 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $163 | $186 | $208 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $312 | $321 | $338 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $312 | $348 | $380 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $84 | $84 | $84 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $54 | $92 |
| Ultrasound transvaginal CPT 76830 • Imaging | $92 | $110 | $127 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $77 | $77 | $77 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $95 | $103 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $54 | $54 | $54 |
| Screening mammography bilateral CPT 77067 • Imaging | $100 | $106 | $112 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $30 | $30 | $30 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $391 | $678 | $1,154 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $4 | $5 | $7 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $4 | $4 | $4 |
| Lipid panel CPT 80061 • Laboratory | $6 | $8 | $11 |
| Hepatic function panel CPT 80076 • Laboratory | $3 | $5 | $7 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $2 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $1 | $2 | $2 |
| Fecal hemoglobin immunoassay CPT 82274 • Laboratory | $10 | $11 | $13 |