| CT maxillofacial with contrast CPT 70487 • Imaging | $99 | $210 | $321 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $121 | $211 |
| CT angiography neck CPT 70498 • Imaging | $30 | $244 | $627 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $409 | $1,107 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $132 | $226 |
| MRI brain with contrast CPT 70552 • Imaging | $299 | $590 | $882 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $323 | $690 |
| Chest X-ray single view CPT 71045 • Imaging | $14 | $36 | $81 |
| Chest X-ray 2 views CPT 71046 • Imaging | $36 | $48 | $72 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $143 | $267 |
| CT chest with contrast CPT 71260 • Imaging | $71 | $197 | $363 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $110 | $190 |
| CT angiography chest CPT 71275 • Imaging | $157 | $317 | $635 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $131 | $269 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $179 | $421 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $128 | $267 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $260 | $621 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $238 | $621 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $30 | $244 | $623 |
| CT pelvis without contrast CPT 72192 • Imaging | $95 | $264 | $432 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $103 | $177 |
| X-ray shoulder complete CPT 73030 • Imaging | $30 | $62 | $108 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $119 | $389 | $659 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $16 | $51 | $107 |
| X-ray ankle complete CPT 73610 • Imaging | $16 | $54 | $115 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $117 | $178 | $211 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $118 | $186 | $211 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $167 | $444 |
| CT abdomen with contrast CPT 74160 • Imaging | $111 | $436 | $761 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $264 | $641 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $152 | $215 | $330 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $200 | $454 | $991 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $176 | $286 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $70 | $218 | $367 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $74 | $112 |
| Ultrasound transvaginal CPT 76830 • Imaging | $92 | $224 | $376 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $184 | $258 | $332 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $64 | $95 | $110 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $79 | $107 | $134 |
| Screening mammography bilateral CPT 77067 • Imaging | $59 | $142 | $253 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $18 | $68 | $118 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $138 | $700 | $1,154 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $7 | $9 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $11 | $11 | $12 |
| Lipid panel CPT 80061 • Laboratory | $11 | $14 | $19 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $9 | $11 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $3 | $3 | $5 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $3 | $3 | $3 |
| Urinalysis automated without microscopy CPT 81003 • Laboratory | $2 | $2 | $3 |