| Arthrocentesis (outpatient) | $1,713 | 65% | $599 | 
High |
| Arthroscopic Knee Surgery (outpatient) | $14,977 | 65% | $5,242 | 
Medium |
| Arthroscopic Shoulder Surgery | $34,574 | 65% | $12,101 |
Medium |
| Bacterial Culture Swab | $124 | 65% | $43 |
Medium |
| Biopsy - Endometrial (Uterus) | $1,490 | 65% | $521 |
Medium |
| Blood Test - Basic Metabolic Panel | $176 | 65% | $62 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $87 | 65% | $31 |
Medium |
| Blood Test - Clotting Time | $36 | 65% | $12 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $88 | 65% | $31 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $69 | 65% | $24 |
Medium |
| Blood Test - Electrolytes Panel | $92 | 65% | $32 |
Medium |
| Blood Test - General Health Panel | $174 | 65% | $61 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $162 | 65% | $57 |
Medium |
| Blood Test - Hepatitis C Antibody Level | $119 | 65% | $42 |
Medium |
| Blood Test - LDL Cholesterol Level | $65 | 65% | $23 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $176 | 65% | $62 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $215 | 65% | $75 |
Medium |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $151 | 65% | $53 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $81 | 65% | $28 |
Medium |
| Blood Test - Vitamin D-3 Level | $292 | 65% | $102 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $6,642 | 65% | $2,325 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $8,246 | 65% | $2,886 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $9,116 | 65% | $3,191 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $4,472 | 65% | $1,565 |
Medium |
| CT Scan - Chest, with Contrast (outpatient) | $3,074 | 65% | $1,076 |
Medium |
| CT Scan - Head/Brain, without Contrast | $1,584 | 65% | $555 |
Medium |
| Cystoscopy | $1,322 | 65% | $463 |
High |
| Detection Test for Human Papillomavirus (HPV) | $234 | 65% | $82 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $340 | 65% | $119 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $223 | 65% | $78 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $590 | 65% | $207 |
Medium |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $95 | 65% | $33 |
Medium |
| Fetal Non-Stress Test | $805 | 65% | $282 |
Medium |
| Gall Bladder Surgery (outpatient) | $15,425 | 65% | $5,399 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $18,766 | 65% | $6,568 |
Medium |
| Mammogram (outpatient) | $1,051 | 65% | $368 |
Medium |
| MRI - Back (outpatient) | $3,956 | 65% | $1,385 |
Medium |
| MRI - Brain (outpatient) | $7,768 | 65% | $2,719 |
High |
| MRI - Knee (outpatient) | $2,684 | 65% | $939 |
Medium |
| MRI - Pelvis (outpatient) | $5,391 | 65% | $1,887 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $2,684 | 65% | $939 |
Medium |
| Myocardial Imaging (outpatient) | $10,394 | 65% | $3,638 |
Medium |
| Pap Test | $188 | 65% | $66 |
Medium |
| Physical Therapy - Electrical Stimulation Therapy | $79 | 65% | $28 |
Medium |
| Physical Therapy - High Complexity Evaluation | $564 | 65% | $197 |
Medium |
| Physical Therapy - Manual Therapy | $141 | 65% | $49 |
Medium |
| Physical Therapy - Self-care or Home Management Training | $141 | 65% | $49 |
Medium |
| Physical Therapy - Therapeutic Activities | $141 | 65% | $49 |
Medium |
| Physical Therapy - Therapeutic Exercises | $141 | 65% | $49 |
Medium |
| Psychiatric Diagnostic Evaluation | $246 | 65% | $86 |
Medium |
| Psychotherapy - 30 Minutes | $85 | 65% | $30 |
Medium |
| Psychotherapy - Group Session | $103 | 65% | $36 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $62 | 65% | $22 |
Medium |
| Ultrasound - Abdominal, Complete | $1,194 | 65% | $418 |
Medium |
| Ultrasound - Abdominal, Limited | $959 | 65% | $336 |
Medium |
| Ultrasound - Breast (outpatient) | $461 | 65% | $161 |
Medium |
| Ultrasound - Head and Neck | $960 | 65% | $336 |
High |
| Ultrasound - Transvaginal (non-maternity) | $967 | 65% | $338 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,562 | 65% | $2,297 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,307 | 65% | $2,907 |
Medium |
| Urine Capacity Measurement | $761 | 65% | $266 |
Medium |
| Urine Test - Automated with Microscope Examination | $54 | 65% | $19 |
Medium |
| Urine Test - Automated without Microscope | $26 | 65% | $9 |
Medium |
| Urine Test - Chlamydia | $213 | 65% | $75 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $213 | 65% | $75 |
Medium |
| Urine Test - Pregnancy | $118 | 65% | $41 |
Medium |
| X-Ray - Abdomen | $734 | 65% | $257 |
Medium |
| X-Ray - Ankle (outpatient) | $449 | 65% | $157 |
Medium |
| X-Ray - Chest (outpatient) | $795 | 65% | $278 |
High |
| X-Ray - Foot (outpatient) | $777 | 65% | $272 |
High |
| X-Ray - Hand | $739 | 65% | $259 |
Medium |
| X-Ray - Hip | $758 | 65% | $265 |
High |
| X-Ray - Knee (outpatient) | $827 | 65% | $290 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $529 | 65% | $185 |
High |
| X-Ray - Neck, Cervical Spine | $828 | 65% | $290 |
Medium |
| X-Ray - Pelvis | $624 | 65% | $218 |
Medium |
| X-Ray - Shoulder (outpatient) | $873 | 65% | $305 |
Medium |
| X-Ray - Spine (outpatient) | $827 | 65% | $290 |
Medium |
| X-Ray - Wrist (outpatient) | $819 | 65% | $287 |
High |
