| CT head with contrast CPT 70460 • Imaging | $30 | $203 | $480 |
| CT head without then with contrast CPT 70470 • Imaging | $194 | $194 | $194 |
| CT maxillofacial without contrast CPT 70486 • Imaging | $30 | $79 | $133 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $56 | $77 | $99 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $30 | $125 | $224 |
| CT angiography neck CPT 70498 • Imaging | $30 | $333 | $894 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $30 | $197 | $327 |
| MRI brain without contrast CPT 70551 • Imaging | $40 | $128 | $200 |
| MRI brain with contrast CPT 70552 • Imaging | $214 | $245 | $276 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $30 | $216 | $359 |
| Chest X-ray single view CPT 71045 • Imaging | $14 | $28 | $53 |
| Chest X-ray 2 views CPT 71046 • Imaging | $9 | $25 | $54 |
| CT chest without contrast CPT 71250 • Imaging | $30 | $182 | $432 |
| CT chest with contrast CPT 71260 • Imaging | $71 | $113 | $155 |
| CT chest without then with contrast CPT 71270 • Imaging | $30 | $239 | $447 |
| CT angiography chest CPT 71275 • Imaging | $159 | $350 | $635 |
| CT cervical spine without contrast CPT 72125 • Imaging | $30 | $82 | $122 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $30 | $79 | $121 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $30 | $56 | $87 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $30 | $187 | $395 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $30 | $49 | $73 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $129 | $165 | $196 |
| CT pelvis without contrast CPT 72192 • Imaging | $95 | $130 | $166 |
| CT pelvis with contrast CPT 72193 • Imaging | $30 | $293 | $747 |
| X-ray shoulder complete CPT 73030 • Imaging | $27 | $34 | $48 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $119 | $237 | $451 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $29 | $54 | $107 |
| X-ray ankle complete CPT 73610 • Imaging | $30 | $66 | $115 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $117 | $423 | $729 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $30 | $140 | $207 |
| CT abdomen without contrast CPT 74150 • Imaging | $30 | $113 | $181 |
| CT abdomen with contrast CPT 74160 • Imaging | $111 | $133 | $155 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $30 | $110 | $179 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $76 | $197 | $330 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $200 | $276 | $313 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $176 | $303 | $351 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $70 | $99 | $123 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $30 | $65 | $96 |
| Ultrasound transvaginal CPT 76830 • Imaging | $61 | $91 | $107 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $34 | $52 | $63 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $64 | $122 | $239 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $79 | $174 | $305 |
| Screening mammography bilateral CPT 77067 • Imaging | $59 | $126 | $253 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $18 | $23 | $29 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $138 | $326 | $391 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $2 | $3 |
| Basic metabolic panel CPT 80048 • Laboratory | $1 | $7 | $11 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $8 | $10 | $12 |
| Lipid panel CPT 80061 • Laboratory | $11 | $14 | $19 |
| Hepatic function panel CPT 80076 • Laboratory | $7 | $9 | $11 |