| Arthrocentesis (outpatient) | $1,769 | 65% | $619 |
| Bacterial Culture - Aerobic Isolates | $79 | 65% | $28 |
| Bacterial Culture - Swab | $124 | 65% | $43 |
| Biopsy - Breast | $10,397 | 65% | $3,639 |
| Biopsy - Endometrial (Uterus) | $1,609 | 65% | $563 |
| Blood Test - Basic Metabolic Panel | $68 | 65% | $24 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $87 | 65% | $31 |
| Blood Test - Cholesterol Test, Lipid Panel | $107 | 65% | $37 |
| Blood Test - Clotting Time | $36 | 65% | $12 |
| Blood Test - Coagulation Assessment | $139 | 65% | $49 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $88 | 65% | $31 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $69 | 65% | $24 |
| Blood Test - Electrolytes Panel | $95 | 65% | $33 |
| Blood Test - General Health Panel | $174 | 65% | $61 |
| Blood Test - Hepatic (Liver) Function Panel | $162 | 65% | $57 |
| Blood Test - Hepatitis C Antibody Level | $119 | 65% | $42 |
| Blood Test - Iron Level | $69 | 65% | $24 |
| Blood Test - LDL Cholesterol Level | $65 | 65% | $23 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $176 | 65% | $62 |
| Blood Test - Renal (Kidney) Function Panel | $215 | 65% | $75 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $151 | 65% | $53 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $81 | 65% | $28 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $159 | 65% | $55 |
| Blood Test - Vitamin D-3 Level | $292 | 65% | $102 |
| Bone Density Scan (outpatient) | $709 | 65% | $248 |
| Colonoscopy - Diagnostic (outpatient) | $6,798 | 65% | $2,379 |
| Colonoscopy - With Biopsy (outpatient) | $8,382 | 65% | $2,934 |
| Colonoscopy - With Polyp Removal (outpatient) | $9,171 | 65% | $3,210 |
| CT Scan - Abdomen and Pelvis, with Contrast | $4,495 | 65% | $1,573 |
| CT Scan - Chest, with Contrast (outpatient) | $3,167 | 65% | $1,109 |
| CT Scan - Head/Brain, without Contrast | $1,640 | 65% | $574 |
| Cystoscopy | $1,305 | 65% | $457 |
| Detection test for Human Papillomavirus (HPV) | $234 | 65% | $82 |
| Emergency Department Visit - Low Complexity (outpatient) | $340 | 65% | $119 |
| Emergency Department Visit - Minor (outpatient) | $223 | 65% | $78 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $590 | 65% | $207 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $99 | 65% | $35 |
| Fetal Non-Stress Test | $790 | 65% | $277 |
| Gall Bladder Surgery (outpatient) | $15,190 | 65% | $5,317 |
| Hernia Repair - Laparoscopic (outpatient) | $18,074 | 65% | $6,326 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $62 | 65% | $22 |
| Lab Test - Smear for Microorganism | $62 | 65% | $22 |
| Mammogram (outpatient) | $1,051 | 65% | $368 |
| MRI - Back (outpatient) | $4,029 | 65% | $1,410 |
| MRI - Brain (outpatient) | $7,781 | 65% | $2,723 |
| MRI - Knee (outpatient) | $2,684 | 65% | $939 |
| MRI - Pelvis (outpatient) | $5,537 | 65% | $1,938 |
| MRI - Shoulder, Elbow, or Wrist | $2,684 | 65% | $939 |
| Myocardial Imaging (outpatient) | $10,799 | 65% | $3,780 |
| Pap Test | $188 | 65% | $66 |
| Physical Therapy - Application of Hot or Cold Pack | $80 | 65% | $28 |
| Physical Therapy - High Complexity Evaluation | $564 | 65% | $197 |
| Physical Therapy - Manual Therapy | $141 | 65% | $49 |
| Physical Therapy - Self-care or Home Management Training | $141 | 65% | $49 |
| Physical Therapy - Therapeutic Activities | $141 | 65% | $49 |
| Physical Therapy - Therapeutic Exercises | $141 | 65% | $49 |
| Psychotherapy - 30 Minutes | $85 | 65% | $30 |
| Psychotherapy - Group Session | $107 | 65% | $37 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $62 | 65% | $22 |
| Ultrasound - Abdominal, Complete | $1,194 | 65% | $418 |
| Ultrasound - Abdominal, Limited | $992 | 65% | $347 |
| Ultrasound - Breast (outpatient) | $484 | 65% | $169 |
| Ultrasound - Head and Neck | $977 | 65% | $342 |
| Ultrasound - Transvaginal (non-maternity) | $1,000 | 65% | $350 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,389 | 65% | $2,236 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,118 | 65% | $2,841 |
| Urine Capacity Measurement | $736 | 65% | $258 |
| Urine Test - Automated with Microscope Examination | $54 | 65% | $19 |
| Urine Test - Automated without Microscope | $26 | 65% | $9 |
| Urine Test - Chlamydia | $213 | 65% | $75 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $213 | 65% | $75 |
| Urine Test - Microalbumin (Protein) Level | $48 | 65% | $17 |
| Urine Test - Pregnancy | $118 | 65% | $41 |
| X-Ray - Abdomen | $734 | 65% | $257 |
| X-Ray - Ankle (outpatient) | $466 | 65% | $163 |
| X-Ray - Chest (outpatient) | $795 | 65% | $278 |
| X-Ray - Foot (outpatient) | $668 | 65% | $234 |
| X-Ray - Hand | $738 | 65% | $258 |
| X-Ray - Hip | $758 | 65% | $265 |
| X-Ray - Knee (outpatient) | $827 | 65% | $290 |
| X-Ray - Middle Back, Thoracic Spine | $608 | 65% | $213 |
| X-Ray - Neck, Cervical Spine | $751 | 65% | $263 |
| X-Ray - Pelvis | $610 | 65% | $213 |
| X-Ray - Shoulder (outpatient) | $873 | 65% | $305 |
| X-Ray - Spine (outpatient) | $747 | 65% | $261 |
| X-Ray - Wrist (outpatient) | $757 | 65% | $265 |
