| Arthrocentesis (outpatient) | $1,365 | 68% | $437 |
| Bacterial Culture - Aerobic Isolates | $87 | 68% | $28 |
| Bacterial Culture - Swab | $146 | 68% | $47 |
| Biopsy - Breast | $7,615 | 68% | $2,437 |
| Biopsy - Punch Biopsy of Skin | $793 | 68% | $254 |
| Blood Test - Basic Metabolic Panel | $76 | 68% | $24 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $101 | 68% | $32 |
| Blood Test - Cholesterol Test, Lipid Panel | $138 | 68% | $44 |
| Blood Test - Clotting Time | $53 | 68% | $17 |
| Blood Test - Coagulation Assessment | $76 | 68% | $24 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $67 | 68% | $22 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $86 | 68% | $28 |
| Blood Test - Comprehensive Metabolic Panel | $103 | 68% | $33 |
| Blood Test - Electrolytes Panel | $95 | 68% | $30 |
| Blood Test - Ferritin (Blood Protein) Level | $141 | 68% | $45 |
| Blood Test - Folic Acid Level | $137 | 68% | $44 |
| Blood Test - General Health Panel | $337 | 68% | $108 |
| Blood Test - Hepatic (Liver) Function Panel | $86 | 68% | $28 |
| Blood Test - Hepatitis C Antibody Level | $140 | 68% | $45 |
| Blood Test - Iron Level | $97 | 68% | $31 |
| Blood Test - LDL Cholesterol Level | $84 | 68% | $27 |
| Blood Test - Lipase (fat enzyme) Level | $109 | 68% | $35 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $145 | 68% | $46 |
| Blood Test - Renal (Kidney) Function Panel | $95 | 68% | $30 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $148 | 68% | $47 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $117 | 68% | $37 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $275 | 68% | $88 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $147 | 68% | $47 |
| Blood Test - Vitamin D-3 Level | $234 | 68% | $75 |
| Bone Density Scan (outpatient) | $576 | 68% | $184 |
| Colonoscopy - Diagnostic (outpatient) | $3,884 | 68% | $1,243 |
| Colonoscopy - With Biopsy (outpatient) | $4,361 | 68% | $1,395 |
| Colonoscopy - With Polyp Removal (outpatient) | $4,837 | 68% | $1,548 |
| CT Scan - Abdomen and Pelvis, with Contrast | $4,977 | 68% | $1,593 |
| CT Scan - Chest, with Contrast (outpatient) | $2,675 | 68% | $856 |
| CT Scan - Head/Brain, without Contrast | $1,944 | 68% | $622 |
| Detection test for Human Papillomavirus (HPV) | $342 | 68% | $110 |
| Electrocardiogram (ECG or EKG) | $489 | 68% | $157 |
| Emergency Department Visit - Low Complexity (outpatient) | $470 | 68% | $151 |
| Emergency Department Visit - Minor (outpatient) | $268 | 68% | $86 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $961 | 68% | $307 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $137 | 68% | $44 |
| Fetal Non-Stress Test | $909 | 68% | $291 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $131 | 68% | $42 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $195 | 68% | $62 |
| Lab Test - Detection test for Influenza Virus | $40 | 68% | $13 |
| Lab Test - Smear for Microorganism | $67 | 68% | $22 |
| Mammogram (outpatient) | $962 | 68% | $308 |
| MRI - Back (outpatient) | $3,599 | 68% | $1,152 |
| MRI - Brain (outpatient) | $5,944 | 68% | $1,902 |
| Myocardial Imaging (outpatient) | $12,643 | 68% | $4,046 |
| Office Visit - Basic | $111 | 68% | $36 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $228 | 68% | $73 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $244 | 68% | $78 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $244 | 68% | $78 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $284 | 68% | $91 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $225 | 68% | $72 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $212 | 68% | $68 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $191 | 68% | $61 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $210 | 68% | $67 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $210 | 68% | $67 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $228 | 68% | $73 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $190 | 68% | $61 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $172 | 68% | $55 |
| Office Visit - Established Patient, High Complexity | $359 | 68% | $115 |
| Office Visit - Established Patient, Low Complexity | $182 | 68% | $58 |
| Office Visit - Established Patient, Moderate Complexity | $263 | 68% | $84 |
| Office Visit - New Patient, Low Complexity | $268 | 68% | $86 |
| Office Visit - New Patient, Minor | $188 | 68% | $60 |
| Office Visit - New Patient, Moderate Complexity | $236 | 68% | $76 |
| Physical Therapy - Electrical Stimulation Therapy | $83 | 68% | $27 |
| Physical Therapy - High Complexity Evaluation | $327 | 68% | $104 |
| Physical Therapy - Low Complexity Evaluation | $327 | 68% | $104 |
| Physical Therapy - Manual Electrical Stimulation Therapy, 15 minutes | $84 | 68% | $27 |
| Physical Therapy - Manual Therapy | $139 | 68% | $44 |
| Physical Therapy - Moderate Complexity Evaluation | $327 | 68% | $104 |
| Physical Therapy - Neuromuscular Reeducation | $89 | 68% | $28 |
| Physical Therapy - Re-Evaluation | $142 | 68% | $45 |
| Physical Therapy - Self-care or Home Management Training | $92 | 68% | $29 |
| Physical Therapy - Therapeutic Activities | $92 | 68% | $29 |
| Physical Therapy - Therapeutic Exercises | $133 | 68% | $43 |
| Psychiatric Diagnostic Evaluation | $149 | 68% | $48 |
| Psychotherapy - 30 Minutes | $84 | 68% | $27 |
| Psychotherapy - 45 Minutes | $133 | 68% | $43 |
| Psychotherapy - 60 Minutes | $137 | 68% | $44 |
| Psychotherapy - Family Session | $146 | 68% | $47 |
| Psychotherapy - Group Session | $137 | 68% | $44 |
| Strep Test (Streptococcus, group A) | $41 | 68% | $13 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $79 | 68% | $25 |
| Ultrasound - Abdominal, Complete | $1,142 | 68% | $366 |
| Ultrasound - Abdominal, Limited | $906 | 68% | $290 |
| Ultrasound - Breast (outpatient) | $1,304 | 68% | $417 |
| Ultrasound - Head and Neck | $930 | 68% | $298 |
| Ultrasound - Pregnancy (outpatient) | $980 | 68% | $313 |
| Ultrasound - Pregnancy Follow-Up | $646 | 68% | $207 |
| Ultrasound - Transvaginal (non-maternity) | $779 | 68% | $249 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $8,688 | 68% | $2,780 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,753 | 68% | $1,841 |
| Urine Capacity Measurement | $618 | 68% | $198 |
| Urine Test - Automated with Microscope Examination | $87 | 68% | $28 |
| Urine Test - Automated without Microscope | $42 | 68% | $13 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $66 | 68% | $21 |
| Urine Test - Microalbumin (Protein) Level | $91 | 68% | $29 |
| Urine Test - Pregnancy | $23 | 68% | $7 |
| Urine Test - Urinalysis, Manual Test | $9 | 68% | $3 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $307 | 68% | $98 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $77 | 68% | $25 |
| X-Ray - Abdomen | $581 | 68% | $186 |
| X-Ray - Ankle (outpatient) | $411 | 68% | $131 |
| X-Ray - Chest (outpatient) | $499 | 68% | $160 |
| X-Ray - Foot (outpatient) | $424 | 68% | $136 |
| X-Ray - Hand | $470 | 68% | $151 |
| X-Ray - Hip | $686 | 68% | $219 |
| X-Ray - Knee (outpatient) | $408 | 68% | $131 |
| X-Ray - Middle Back, Thoracic Spine | $772 | 68% | $247 |
| X-Ray - Neck, Cervical Spine | $589 | 68% | $188 |
| X-Ray - Shoulder (outpatient) | $426 | 68% | $136 |
| X-Ray - Spine (outpatient) | $601 | 68% | $192 |
| X-Ray - Wrist (outpatient) | $403 | 68% | $129 |
