| Arthrocentesis (outpatient) | $1,001 | 0% | $1,001 |
| Bacterial Culture - Aerobic Isolates | $28 | 0% | $28 |
| Bacterial Culture - Swab | $46 | 0% | $46 |
| Biopsy - Breast | $3,494 | 0% | $3,494 |
| Biopsy - Endometrial (Uterus) | $1,071 | 0% | $1,071 |
| Blood Test - Basic Metabolic Panel | $30 | 0% | $30 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $34 | 0% | $34 |
| Blood Test - Cholesterol Test, Lipid Panel | $82 | 0% | $82 |
| Blood Test - Clotting Time | $17 | 0% | $17 |
| Blood Test - Coagulation Assessment | $47 | 0% | $47 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $49 | 0% | $49 |
| Blood Test - Comprehensive Metabolic Panel | $37 | 0% | $37 |
| Blood Test - Electrolytes Panel | $47 | 0% | $47 |
| Blood Test - Ferritin (Blood Protein) Level | $85 | 0% | $85 |
| Blood Test - Folic Acid Level | $111 | 0% | $111 |
| Blood Test - General Health Panel | $198 | 0% | $198 |
| Blood Test - Hepatic (Liver) Function Panel | $65 | 0% | $65 |
| Blood Test - Hepatitis C Antibody Level | $76 | 0% | $76 |
| Blood Test - Iron Level | $44 | 0% | $44 |
| Blood Test - LDL Cholesterol Level | $57 | 0% | $57 |
| Blood Test - Lipase (fat enzyme) Level | $24 | 0% | $24 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $114 | 0% | $114 |
| Blood Test - Renal (Kidney) Function Panel | $97 | 0% | $97 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $112 | 0% | $112 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $62 | 0% | $62 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $97 | 0% | $97 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $57 | 0% | $57 |
| Blood Test - Vitamin D-3 Level | $151 | 0% | $151 |
| Bone Density Scan (outpatient) | $452 | 0% | $452 |
| Chiropractic Manipulative Treatment - Spinal, 1-2 Regions | $47 | 0% | $47 |
| Chiropractic Manipulative Treatment - Spinal, 3-4 Regions | $53 | 0% | $53 |
| Colonoscopy - Diagnostic (outpatient) | $4,495 | 0% | $4,495 |
| Colonoscopy - With Biopsy (outpatient) | $5,534 | 0% | $5,534 |
| Colonoscopy - With Polyp Removal (outpatient) | $5,388 | 0% | $5,388 |
| CT Scan - Abdomen and Pelvis, with Contrast | $2,144 | 0% | $2,144 |
| CT Scan - Chest, with Contrast (outpatient) | $1,750 | 0% | $1,750 |
| CT Scan - Head/Brain, without Contrast | $852 | 0% | $852 |
| Emergency Department Visit - Low Complexity (outpatient) | $219 | 0% | $219 |
| Emergency Department Visit - Minor (outpatient) | $205 | 0% | $205 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $324 | 0% | $324 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $39 | 0% | $39 |
| Fetal Non-Stress Test | $734 | 0% | $734 |
| Gall Bladder Surgery (outpatient) | $11,524 | 0% | $11,524 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $64 | 0% | $64 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $71 | 0% | $71 |
| Lab Test - Detection test for Influenza Virus | $47 | 0% | $47 |
| Lab Test - Smear for Microorganism | $23 | 0% | $23 |
| Mammogram (outpatient) | $767 | 0% | $767 |
| Office Visit - Basic | $139 | 0% | $139 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $368 | 0% | $368 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $424 | 0% | $424 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $284 | 0% | $284 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $310 | 0% | $310 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $341 | 0% | $341 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $370 | 0% | $370 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $284 | 0% | $284 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $273 | 0% | $273 |
| Office Visit - Established Patient, High Complexity | $473 | 0% | $473 |
| Office Visit - Established Patient, Low Complexity | $221 | 0% | $221 |
| Office Visit - Established Patient, Moderate Complexity | $333 | 0% | $333 |
| Office Visit - New Patient, Low Complexity | $305 | 0% | $305 |
| Office Visit - New Patient, Minor | $197 | 0% | $197 |
| Physical Therapy - Low Complexity Evaluation | $289 | 0% | $289 |
| Physical Therapy - Manual Therapy | $116 | 0% | $116 |
| Physical Therapy - Moderate Complexity Evaluation | $289 | 0% | $289 |
| Physical Therapy - Neuromuscular Reeducation | $42 | 0% | $42 |
| Physical Therapy - Therapeutic Activities | $137 | 0% | $137 |
| Physical Therapy - Therapeutic Exercises | $124 | 0% | $124 |
| Physical Therapy - Ultrasound Therapy | $49 | 0% | $49 |
| Strep Test (Streptococcus, group A) | $42 | 0% | $42 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $45 | 0% | $45 |
| Ultrasound - Abdominal, Complete | $695 | 0% | $695 |
| Ultrasound - Abdominal, Limited | $528 | 0% | $528 |
| Ultrasound - Breast (outpatient) | $875 | 0% | $875 |
| Ultrasound - Head and Neck | $511 | 0% | $511 |
| Ultrasound - Pregnancy (outpatient) | $577 | 0% | $577 |
| Ultrasound - Pregnancy Follow-Up | $524 | 0% | $524 |
| Ultrasound - Transvaginal (non-maternity) | $741 | 0% | $741 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $4,495 | 0% | $4,495 |
| Urine Capacity Measurement | $721 | 0% | $721 |
| Urine Test - Automated with Microscope Examination | $33 | 0% | $33 |
| Urine Test - Automated without Microscope | $25 | 0% | $25 |
| Urine Test - Bacterial Culture | $53 | 0% | $53 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $32 | 0% | $32 |
| Urine Test - Chlamydia | $83 | 0% | $83 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $95 | 0% | $95 |
| Urine Test - Microalbumin (Protein) Level | $46 | 0% | $46 |
| Urine Test - Pregnancy | $30 | 0% | $30 |
| Urine Test - Urinalysis, Manual Test | $17 | 0% | $17 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $247 | 0% | $247 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $79 | 0% | $79 |
| X-Ray - Abdomen | $418 | 0% | $418 |
| X-Ray - Ankle (outpatient) | $558 | 0% | $558 |
| X-Ray - Chest (outpatient) | $576 | 0% | $576 |
| X-Ray - Foot (outpatient) | $503 | 0% | $503 |
| X-Ray - Hand | $647 | 0% | $647 |
| X-Ray - Hip | $638 | 0% | $638 |
| X-Ray - Knee (outpatient) | $562 | 0% | $562 |
| X-Ray - Middle Back, Thoracic Spine | $990 | 0% | $990 |
| X-Ray - Shoulder (outpatient) | $573 | 0% | $573 |
| X-Ray - Spine (outpatient) | $754 | 0% | $754 |
| X-Ray - Wrist (outpatient) | $458 | 0% | $458 |
