| Bacterial Culture - Swab | $85 | N/A | $85 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $48 | N/A | $48 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $137 | N/A | $137 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $186 | N/A | $186 |
| Lab Test - Detection test for Human Papillomavirus (HPV) | $137 | N/A | $137 |
| Lab Test - Smear for Microorganism | $39 | N/A | $39 |
| Mammogram (outpatient) | $960 | N/A | $960 |
| Office Visit - Basic | $84 | N/A | $84 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $252 | N/A | $252 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $284 | N/A | $284 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $231 | N/A | $231 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $242 | N/A | $242 |
| Office Visit - Established Patient, High Complexity | $284 | N/A | $284 |
| Office Visit - Established Patient, Low Complexity | $152 | N/A | $152 |
| Office Visit - Established Patient, Moderate Complexity | $210 | N/A | $210 |
| Pap Test, automated screening and manual rescreening | $126 | N/A | $126 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $16 | N/A | $16 |
| Ultrasound - Pelvic (outpatient) | $423 | N/A | $423 |
| Ultrasound - Pregnancy (outpatient) | $389 | N/A | $389 |
| Ultrasound - Pregnancy Follow-Up | $389 | N/A | $389 |
| Ultrasound - Transvaginal (non-maternity) | $467 | N/A | $467 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $113 | N/A | $113 |
| Urine Test - Chlamydia | $109 | N/A | $109 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $109 | N/A | $109 |
| Urine Test - Pregnancy | $22 | N/A | $22 |
| Urine Test - Urinalysis, Manual Test | $16 | N/A | $16 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $63 | N/A | $63 |
