| CT maxillofacial without contrast CPT 70486 • Imaging | $41 | $126 | $212 |
| CT maxillofacial with contrast CPT 70487 • Imaging | $54 | $155 | $255 |
| CT soft tissue neck with contrast CPT 70491 • Imaging | $66 | $133 | $199 |
| CT angiography neck CPT 70498 • Imaging | $83 | $265 | $447 |
| MRI orbits face neck with and without contrast CPT 70543 • Imaging | $103 | $353 | $602 |
| MRI brain without contrast CPT 70551 • Imaging | $71 | $94 | $117 |
| MRI brain with contrast CPT 70552 • Imaging | $337 | $337 | $337 |
| MRI brain without contrast then with contrast CPT 70553 • Imaging | $181 | $252 | $323 |
| Chest X-ray single view CPT 71045 • Imaging | $14 | $17 | $19 |
| Chest X-ray 2 views CPT 71046 • Imaging | $10 | $16 | $21 |
| CT chest without contrast CPT 71250 • Imaging | $52 | $147 | $242 |
| CT chest with contrast CPT 71260 • Imaging | $56 | $77 | $98 |
| CT chest without then with contrast CPT 71270 • Imaging | $354 | $354 | $354 |
| CT angiography chest CPT 71275 • Imaging | $144 | $144 | $144 |
| CT cervical spine without contrast CPT 72125 • Imaging | $49 | $67 | $84 |
| CT thoracic spine without contrast CPT 72128 • Imaging | $49 | $161 | $274 |
| CT lumbar spine without contrast CPT 72131 • Imaging | $49 | $121 | $193 |
| MRI cervical spine without contrast CPT 72141 • Imaging | $71 | $204 | $336 |
| MRI thoracic spine without contrast CPT 72146 • Imaging | $71 | $145 | $219 |
| MRI lumbar spine without contrast CPT 72148 • Imaging | $72 | $145 | $219 |
| CT pelvis without contrast CPT 72192 • Imaging | $52 | $137 | $222 |
| CT pelvis with contrast CPT 72193 • Imaging | $56 | $74 | $92 |
| X-ray shoulder complete CPT 73030 • Imaging | $15 | $22 | $30 |
| MRI joint upper extremity without contrast CPT 73221 • Imaging | $209 | $228 | $247 |
| X-ray knee 1-2 views CPT 73560 • Imaging | $8 | $13 | $18 |
| X-ray ankle complete CPT 73610 • Imaging | $14 | $23 | $30 |
| MRI lower extremity without contrast CPT 73718 • Imaging | $64 | $231 | $398 |
| MRI joint lower extremity without contrast CPT 73721 • Imaging | $66 | $210 | $354 |
| CT abdomen without contrast CPT 74150 • Imaging | $57 | $76 | $94 |
| CT abdomen with contrast CPT 74160 • Imaging | $362 | $362 | $362 |
| CT abdomen without then with contrast CPT 74170 • Imaging | $67 | $184 | $300 |
| CT abdomen and pelvis without contrast CPT 74176 • Imaging | $84 | $111 | $138 |
| CT abdomen and pelvis with contrast CPT 74177 • Imaging | $88 | $286 | $485 |
| CT abdomen and pelvis without then with contrast CPT 74178 • Imaging | $97 | $243 | $389 |
| Ultrasound abdominal complete CPT 76700 • Imaging | $39 | $80 | $121 |
| Ultrasound retroperitoneal complete CPT 76770 • Imaging | $36 | $47 | $58 |
| Ultrasound transvaginal CPT 76830 • Imaging | $33 | $44 | $55 |
| Ultrasound pelvic complete CPT 76856 • Imaging | $33 | $73 | $112 |
| Diagnostic mammography unilateral CPT 77065 • Imaging | $39 | $52 | $64 |
| Diagnostic mammography bilateral CPT 77066 • Imaging | $156 | $167 | $178 |
| Screening mammography bilateral CPT 77067 • Imaging | $37 | $48 | $60 |
| DEXA bone density study axial skeleton CPT 77080 • Imaging | $16 | $28 | $40 |
| Nuclear myocardial perfusion study CPT 78452 • Imaging | $305 | $455 | $605 |
| Collection of venous blood by venipuncture CPT 36415 • Laboratory | $2 | $3 | $4 |
| Basic metabolic panel CPT 80048 • Laboratory | $5 | $5 | $6 |
| Comprehensive metabolic panel CPT 80053 • Laboratory | $3 | $5 | $7 |
| Lipid panel CPT 80061 • Laboratory | $6 | $8 | $9 |
| Hepatic function panel CPT 80076 • Laboratory | $5 | $5 | $6 |
| Urinalysis with microscopy CPT 81001 • Laboratory | $2 | $2 | $2 |
| Urinalysis nonautomated without microscopy CPT 81002 • Laboratory | $1 | $2 | $2 |