| Arthrocentesis (outpatient) | $520 | 65% | $182 |
| Arthroscopic Knee Surgery (outpatient) | $11,461 | 65% | $4,012 |
| Bacterial Culture - Swab | $137 | 65% | $48 |
| Blood Test - Basic Metabolic Panel | $161 | 65% | $56 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $106 | 65% | $37 |
| Blood Test - Cholesterol Test, Lipid Panel | $150 | 65% | $53 |
| Blood Test - Clotting Time | $13 | 65% | $4 |
| Blood Test - Coagulation Assessment | $71 | 65% | $25 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $98 | 65% | $34 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $106 | 65% | $37 |
| Blood Test - Comprehensive Metabolic Panel | $213 | 65% | $75 |
| Blood Test - Ferritin (Blood Protein) Level | $146 | 65% | $51 |
| Blood Test - Folic Acid Level | $125 | 65% | $44 |
| Blood Test - General Health Panel | $182 | 65% | $64 |
| Blood Test - Hepatic (Liver) Function Panel | $169 | 65% | $59 |
| Blood Test - Hepatitis C Antibody Level | $131 | 65% | $46 |
| Blood Test - Iron Level | $57 | 65% | $20 |
| Blood Test - LDL Cholesterol Level | $76 | 65% | $26 |
| Blood Test - Lipase (fat enzyme) Level | $130 | 65% | $46 |
| Blood Test - Pregnancy (Obstetric) Panel | $534 | 65% | $187 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $122 | 65% | $43 |
| Blood Test - Renal (Kidney) Function Panel | $125 | 65% | $44 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $141 | 65% | $49 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $150 | 65% | $53 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $142 | 65% | $50 |
| Blood Test - Vitamin D-3 Level | $203 | 65% | $71 |
| Bone Density Scan (outpatient) | $636 | 65% | $223 |
| Colonoscopy - Diagnostic (outpatient) | $4,701 | 65% | $1,645 |
| Colonoscopy - With Biopsy (outpatient) | $5,861 | 65% | $2,051 |
| Colonoscopy - With Polyp Removal (outpatient) | $5,714 | 65% | $2,000 |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,322 | 65% | $1,163 |
| Destruction of Lesion (outpatient) | $294 | 65% | $103 |
| Detection test for Human Papillomavirus (HPV) | $349 | 65% | $122 |
| Electrocardiogram (ECG or EKG) | $624 | 65% | $218 |
| Emergency Department Visit - Low Complexity (outpatient) | $369 | 65% | $129 |
| Emergency Department Visit - Minor (outpatient) | $215 | 65% | $75 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $553 | 65% | $194 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $95 | 65% | $33 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $108 | 65% | $38 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $132 | 65% | $46 |
| Lab Test - Detection test for Influenza Virus | $42 | 65% | $15 |
| Lab Test - Smear for Microorganism | $69 | 65% | $24 |
| Mammogram (outpatient) | $1,033 | 65% | $362 |
| MRI - Back (outpatient) | $3,189 | 65% | $1,116 |
| MRI - Brain (outpatient) | $6,897 | 65% | $2,414 |
| MRI - Knee (outpatient) | $3,301 | 65% | $1,155 |
| MRI - Shoulder, Elbow, or Wrist | $3,270 | 65% | $1,144 |
| Office Visit - Basic | $79 | 65% | $28 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $267 | 65% | $93 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $274 | 65% | $96 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $274 | 65% | $96 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $321 | 65% | $112 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $251 | 65% | $88 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $234 | 65% | $82 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $212 | 65% | $74 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $231 | 65% | $81 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $232 | 65% | $81 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $254 | 65% | $89 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $210 | 65% | $74 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $190 | 65% | $67 |
| Office Visit - Established Patient, High Complexity | $295 | 65% | $103 |
| Office Visit - Established Patient, Low Complexity | $129 | 65% | $45 |
| Office Visit - Established Patient, Moderate Complexity | $204 | 65% | $71 |
| Office Visit - New Patient, Low Complexity | $276 | 65% | $97 |
| Office Visit - New Patient, Minor | $132 | 65% | $46 |
| Office Visit - New Patient, Moderate Complexity | $247 | 65% | $86 |
| Pap Test | $227 | 65% | $79 |
| Physical Therapy - Electrical Stimulation Therapy | $80 | 65% | $28 |
| Physical Therapy - High Complexity Evaluation | $362 | 65% | $127 |
| Physical Therapy - Low Complexity Evaluation | $201 | 65% | $70 |
| Physical Therapy - Manual Therapy | $83 | 65% | $29 |
| Physical Therapy - Moderate Complexity Evaluation | $294 | 65% | $103 |
| Physical Therapy - Neuromuscular Reeducation | $74 | 65% | $26 |
| Physical Therapy - Re-Evaluation | $200 | 65% | $70 |
| Physical Therapy - Self-care or Home Management Training | $54 | 65% | $19 |
| Physical Therapy - Therapeutic Activities | $68 | 65% | $24 |
| Physical Therapy - Therapeutic Exercises | $67 | 65% | $24 |
| Physical Therapy - Ultrasound Therapy | $70 | 65% | $25 |
| Strep Test (Streptococcus, group A) | $34 | 65% | $12 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $106 | 65% | $37 |
| Ultrasound - Abdominal, Complete | $1,527 | 65% | $535 |
| Ultrasound - Abdominal, Limited | $889 | 65% | $311 |
| Ultrasound - Breast (outpatient) | $1,693 | 65% | $592 |
| Ultrasound - Head and Neck | $1,189 | 65% | $416 |
| Ultrasound - Pregnancy (outpatient) | $1,222 | 65% | $428 |
| Ultrasound - Pregnancy Follow-Up | $900 | 65% | $315 |
| Ultrasound - Transvaginal (non-maternity) | $1,357 | 65% | $475 |
| Urine Test - Automated with Microscope Examination | $38 | 65% | $13 |
| Urine Test - Automated without Microscope | $57 | 65% | $20 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $108 | 65% | $38 |
| Urine Test - Chlamydia | $215 | 65% | $75 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $232 | 65% | $81 |
| Urine Test - Microalbumin (Protein) Level | $89 | 65% | $31 |
| Urine Test - Pregnancy | $19 | 65% | $7 |
| Urine Test - Urinalysis, Manual Test | $11 | 65% | $4 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $244 | 65% | $85 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $53 | 65% | $18 |
| X-Ray - Ankle (outpatient) | $736 | 65% | $258 |
| X-Ray - Chest (outpatient) | $573 | 65% | $201 |
| X-Ray - Foot (outpatient) | $665 | 65% | $233 |
| X-Ray - Hand | $877 | 65% | $307 |
| X-Ray - Hip | $502 | 65% | $176 |
| X-Ray - Knee (outpatient) | $820 | 65% | $287 |
| X-Ray - Middle Back, Thoracic Spine | $1,443 | 65% | $505 |
| X-Ray - Neck, Cervical Spine | $544 | 65% | $190 |
| X-Ray - Pelvis | $580 | 65% | $203 |
| X-Ray - Shoulder (outpatient) | $719 | 65% | $252 |
| X-Ray - Spine (outpatient) | $598 | 65% | $209 |
| X-Ray - Wrist (outpatient) | $718 | 65% | $251 |
