| Arthrocentesis (outpatient) | $474 | 65% | $166 | 
Medium |
| Bacterial Culture Swab | $135 | 65% | $47 |
Medium |
| Blood Test - Basic Metabolic Panel | $161 | 65% | $56 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $106 | 65% | $37 |
Medium |
| Blood Test - Cholesterol Test, Lipid Panel | $150 | 65% | $53 |
Medium |
| Blood Test - Clotting Time | $12 | 65% | $4 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $97 | 65% | $34 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $106 | 65% | $37 |
Medium |
| Blood Test - Electrolytes Panel | $80 | 65% | $28 |
Medium |
| Blood Test - Folic Acid Level | $125 | 65% | $44 |
Medium |
| Blood Test - General Health Panel | $78 | 65% | $27 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $168 | 65% | $59 |
Medium |
| Blood Test - Hepatitis C Antibody Level | $131 | 65% | $46 |
Medium |
| Blood Test - LDL Cholesterol Level | $74 | 65% | $26 |
Medium |
| Blood Test - Lipase (fat enzyme) Level | $129 | 65% | $45 |
Medium |
| Blood Test - Pregnancy (Obstetric) Panel | $534 | 65% | $187 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $122 | 65% | $43 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $124 | 65% | $44 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $141 | 65% | $49 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $142 | 65% | $50 |
Medium |
| Blood Test - Vitamin D-3 Level | $203 | 65% | $71 |
Medium |
| Bone Density Scan (outpatient) | $628 | 65% | $220 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $4,667 | 65% | $1,634 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $5,803 | 65% | $2,031 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $5,937 | 65% | $2,078 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,186 | 65% | $1,115 |
Medium |
| Destruction of Lesion (outpatient) | $343 | 65% | $120 |
Medium |
| Detection Test for Human Papillomavirus (HPV) | $349 | 65% | $122 |
Medium |
| Electrocardiogram (ECG or EKG) | $732 | 65% | $256 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $369 | 65% | $129 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $214 | 65% | $75 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $553 | 65% | $194 |
Medium |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $93 | 65% | $33 |
Medium |
| Fetal Non-Stress Test | $594 | 65% | $208 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $15,234 | 65% | $5,332 |
Medium |
| Mammogram (outpatient) | $1,033 | 65% | $362 |
Medium |
| MRI - Back (outpatient) | $3,189 | 65% | $1,116 |
Medium |
| MRI - Brain (outpatient) | $6,605 | 65% | $2,312 |
Medium |
| MRI - Knee (outpatient) | $3,249 | 65% | $1,137 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $3,248 | 65% | $1,137 |
Medium |
| Office Visit - Basic | $79 | 65% | $28 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $252 | 65% | $88 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $274 | 65% | $96 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $274 | 65% | $96 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $321 | 65% | $112 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $251 | 65% | $88 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $234 | 65% | $82 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $212 | 65% | $74 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $229 | 65% | $80 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $230 | 65% | $80 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $252 | 65% | $88 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $208 | 65% | $73 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $188 | 65% | $66 |
Medium |
| Office Visit - Established Patient, High Complexity | $292 | 65% | $102 |
Medium |
| Office Visit - Established Patient, Low Complexity | $129 | 65% | $45 |
Medium |
| Office Visit - Established Patient, Moderate Complexity | $204 | 65% | $71 |
Medium |
| Office Visit - New Patient, Low Complexity | $191 | 65% | $67 |
Medium |
| Office Visit - New Patient, Minor | $130 | 65% | $46 |
Medium |
| Pap Test | $227 | 65% | $79 |
Medium |
| Physical Therapy - Electrical Stimulation Therapy | $77 | 65% | $27 |
Medium |
| Physical Therapy - High Complexity Evaluation | $362 | 65% | $127 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $201 | 65% | $70 |
Medium |
| Physical Therapy - Manual Therapy | $83 | 65% | $29 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $291 | 65% | $102 |
Medium |
| Physical Therapy - Neuromuscular Reeducation | $70 | 65% | $25 |
Medium |
| Physical Therapy - Re-Evaluation | $188 | 65% | $66 |
Medium |
| Physical Therapy - Self-care or Home Management Training | $57 | 65% | $20 |
Medium |
| Physical Therapy - Therapeutic Activities | $67 | 65% | $24 |
Medium |
| Physical Therapy - Therapeutic Exercises | $67 | 65% | $24 |
Medium |
| Physical Therapy - Ultrasound Therapy | $70 | 65% | $25 |
Medium |
| Strep Test (Streptococcus, group A) | $34 | 65% | $12 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $105 | 65% | $37 |
Medium |
| Ultrasound - Abdominal, Complete | $1,147 | 65% | $401 |
Medium |
| Ultrasound - Abdominal, Limited | $777 | 65% | $272 |
Medium |
| Ultrasound - Breast (outpatient) | $1,235 | 65% | $432 |
Medium |
| Ultrasound - Head and Neck | $1,069 | 65% | $374 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $1,001 | 65% | $350 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $900 | 65% | $315 |
Medium |
| Ultrasound - Transvaginal (non-maternity) | $1,285 | 65% | $450 |
Medium |
| Urine Test - Automated with Microscope Examination | $38 | 65% | $13 |
Medium |
| Urine Test - Automated without Microscope | $56 | 65% | $19 |
Medium |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $107 | 65% | $37 |
Medium |
| Urine Test - Chlamydia | $213 | 65% | $75 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $232 | 65% | $81 |
Medium |
| Urine Test - Pregnancy | $19 | 65% | $7 |
Medium |
| X-Ray - Abdomen | $450 | 65% | $158 | 
Low |
| X-Ray - Ankle (outpatient) | $623 | 65% | $218 | 
High |
| X-Ray - Chest (outpatient) | $554 | 65% | $194 |
Medium |
| X-Ray - Foot (outpatient) | $597 | 65% | $209 |
Medium |
| X-Ray - Hand | $733 | 65% | $257 |
Medium |
| X-Ray - Hip | $611 | 65% | $214 |
Medium |
| X-Ray - Knee (outpatient) | $742 | 65% | $260 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $1,443 | 65% | $505 |
Medium |
| X-Ray - Neck, Cervical Spine | $517 | 65% | $181 |
Medium |
| X-Ray - Pelvis | $471 | 65% | $165 |
Medium |
| X-Ray - Shoulder (outpatient) | $698 | 65% | $244 |
Medium |
| X-Ray - Spine (outpatient) | $581 | 65% | $203 |
Medium |
| X-Ray - Wrist (outpatient) | $621 | 65% | $217 |
Medium |
