| CT maxillofacial without contrast CPT 70486 • Imaging | $95 | $176 | $257 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $446 | $446 | $446 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $351 | $351 | $351 |
| CT angiography neck CPT 70498 • Imaging | $62 | $152 | $241 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $846 | $846 | $846 |
| MRI brain without contrast CPT 70551 • Imaging | $315 | $315 | $315 |
| MRI brain with contrast CPT 70552 • Imaging | $208 | $208 | $208 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $267 | $267 | $267 |
| Chest X-ray single view CPT 71045 • Imaging | $16 | $34 | $53 |
| Chest X-ray 2 views CPT 71046 • Imaging | $22 | $25 | $27 |
| CT chest without contrast CPT 71250 • Imaging | $38 | $140 | $241 |
| CT chest with contrast CPT 71260 • Imaging | $41 | $101 | $161 |
| CT chest without then with contrast CPT 71270 • Imaging | $404 | $404 | $404 |
| CT angiography chest CPT 71275 • Imaging | $64 | $319 | $574 |
| CT cervical spine without contrast CPT 72125 • Imaging | $35 | $86 | $137 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $35 | $139 | $243 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $35 | $138 | $241 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $173 | $173 | $173 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $301 | $301 | $301 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $173 | $173 | $173 |
| CT pelvis without contrast CPT 72192 • Imaging | $62 | $106 | $150 |
| CT pelvis with contrast CPT 72193 • Imaging | $515 | $515 | $515 |
| X-ray shoulder complete CPT 73030 • Imaging | $19 | $21 | $23 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $504 | $504 | $504 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $22 | $37 | $53 |
| X-ray ankle complete CPT 73610 • Imaging | $31 | $53 | $75 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $157 | $157 | $157 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $48 | $275 | $503 |
| CT abdomen without contrast CPT 74150 • Imaging | $402 | $402 | $402 |
| CT abdomen with contrast CPT 74160 • Imaging | $175 | $175 | $175 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $145 | $362 | $580 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $62 | $151 | $240 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $65 | $158 | $251 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $727 | $727 | $727 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $331 | $331 | $331 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $80 | $194 | $308 |
| Ultrasound transvaginal CPT 76830 • Imaging | $88 | $92 | $96 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $300 | $300 | $300 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $91 | $101 | $111 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $115 | $126 | $137 |
| Screening mammography bilateral CPT 77067 • Imaging | $101 | $232 | $362 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $29 | $60 | $91 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $321 | $665 | $1,009 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $3 | $4 | $5 |
| Basic metabolic panel CPT 80048 • Laboratory | $8 | $8 | $8 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $7 | $11 |
| Lipid panel CPT 80061 • Laboratory | $3 | $8 | $13 |
| Hepatic function panel CPT 80076 • Laboratory | $8 | $8 | $8 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $3 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $2 | $3 | $3 |