| Arthrocentesis (outpatient) | $729 | 60% | $291 | 
Medium |
| Biopsy - Breast | $4,248 | 60% | $1,699 | 
High |
| Biopsy - Endometrial (Uterus) | $1,494 | 60% | $597 |
Medium |
| Biopsy - Skin Lesion | $1,514 | 60% | $606 |
Medium |
| Blood Test - Basic Metabolic Panel | $92 | 60% | $37 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $107 | 60% | $43 |
Medium |
| Blood Test - Cholesterol Test, Lipid Panel | $122 | 60% | $49 |
Medium |
| Blood Test - Clotting Time | $65 | 60% | $26 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $75 | 60% | $30 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $92 | 60% | $37 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $110 | 60% | $44 |
Medium |
| Blood Test - Electrolytes Panel | $116 | 60% | $46 |
Medium |
| Blood Test - General Health Panel | $344 | 60% | $138 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $95 | 60% | $38 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $170 | 60% | $68 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $92 | 60% | $37 |
Medium |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $156 | 60% | $63 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $155 | 60% | $62 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $170 | 60% | $68 |
Medium |
| Blood Test - Vitamin D-3 Level | $239 | 60% | $96 |
Medium |
| Bone Density Scan (outpatient) | $836 | 60% | $334 |
Medium |
| Chiropractic Manipulative Treatment - Spinal, 3-4 Regions | $74 | 60% | $29 |
Medium |
| Chiropractic Manipulative Treatment - Spinal, 5 Regions | $79 | 60% | $32 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $4,731 | 60% | $1,892 |
High |
| Colonoscopy - With Biopsy (outpatient) | $4,510 | 60% | $1,804 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $6,079 | 60% | $2,431 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $7,830 | 60% | $3,132 |
High |
| CT Scan - Chest, with Contrast (outpatient) | $4,287 | 60% | $1,715 |
Medium |
| CT Scan - Head/Brain, without Contrast | $2,090 | 60% | $836 |
Medium |
| Cystoscopy | $1,431 | 60% | $572 |
High |
| Destruction of Lesion (outpatient) | $580 | 60% | $232 |
Medium |
| Destruction of Lesions, up to 14 | $665 | 60% | $266 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $582 | 60% | $233 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $353 | 60% | $141 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $995 | 60% | $398 |
Medium |
| Fetal Non-Stress Test | $826 | 60% | $331 |
Medium |
| Gall Bladder Surgery (outpatient) | $26,674 | 60% | $10,670 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $28,680 | 60% | $11,472 |
Medium |
| Kidney Stone Removal (outpatient) | $25,737 | 60% | $10,295 |
Medium |
| Mammogram (outpatient) | $761 | 60% | $305 |
High |
| MRI - Back (outpatient) | $4,561 | 60% | $1,824 |
High |
| MRI - Brain (outpatient) | $6,613 | 60% | $2,645 |
High |
| MRI - Knee (outpatient) | $3,583 | 60% | $1,433 |
High |
| MRI - Pelvis (outpatient) | $6,550 | 60% | $2,620 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $3,999 | 60% | $1,600 |
Medium |
| Myocardial Imaging (outpatient) | $6,260 | 60% | $2,504 |
Medium |
| Office Visit - Basic | $160 | 60% | $64 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $290 | 60% | $116 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $341 | 60% | $137 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $341 | 60% | $137 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $419 | 60% | $168 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $288 | 60% | $115 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $265 | 60% | $106 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $257 | 60% | $103 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $293 | 60% | $117 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $301 | 60% | $121 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $341 | 60% | $137 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $265 | 60% | $106 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $227 | 60% | $91 |
Medium |
| Office Visit - Established Patient, High Complexity | $442 | 60% | $177 |
Medium |
| Office Visit - Established Patient, Low Complexity | $217 | 60% | $87 |
Medium |
| Office Visit - Established Patient, Moderate Complexity | $313 | 60% | $125 |
Medium |
| Office Visit - New Patient, Low Complexity | $301 | 60% | $121 |
Medium |
| Office Visit - New Patient, Minor | $248 | 60% | $99 |
Medium |
| Pap Test | $155 | 60% | $62 |
Medium |
| Physical Therapy - High Complexity Evaluation | $374 | 60% | $150 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $259 | 60% | $104 |
Medium |
| Physical Therapy - Manual Therapy | $98 | 60% | $39 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $276 | 60% | $110 |
Medium |
| Physical Therapy - Neuromuscular Reeducation | $93 | 60% | $37 |
Medium |
| Physical Therapy - Re-Evaluation | $129 | 60% | $52 |
Medium |
| Physical Therapy - Therapeutic Activities | $98 | 60% | $39 |
Medium |
| Physical Therapy - Therapeutic Exercises | $98 | 60% | $39 |
Medium |
| Physical Therapy - Ultrasound Therapy | $47 | 60% | $19 |
Medium |
| Psychiatric Diagnostic Evaluation | $210 | 60% | $84 |
Medium |
| Psychotherapy - 45 Minutes | $131 | 60% | $53 |
Medium |
| Psychotherapy - 60 Minutes | $163 | 60% | $65 |
Medium |
| Strep Test (Streptococcus, group A) | $72 | 60% | $29 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $97 | 60% | $39 |
Medium |
| Tonsillectomy with Adenoidectomy (outpatient) | $7,762 | 60% | $3,105 |
Medium |
| Ultrasound - Abdominal, Complete | $1,562 | 60% | $625 |
High |
| Ultrasound - Abdominal, Limited | $1,132 | 60% | $453 |
Medium |
| Ultrasound - Breast (outpatient) | $1,033 | 60% | $413 |
High |
| Ultrasound - Head and Neck | $1,112 | 60% | $445 |
Medium |
| Ultrasound - Pelvic (outpatient) | $515 | 60% | $206 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $323 | 60% | $129 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $459 | 60% | $184 |
Medium |
| Ultrasound - Transvaginal (non-maternity) | $960 | 60% | $384 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $3,512 | 60% | $1,405 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,199 | 60% | $2,080 |
Medium |
| Urine Capacity Measurement | $484 | 60% | $194 |
Medium |
| Urine Test - Automated with Microscope Examination | $65 | 60% | $26 |
Medium |
| Urine Test - Automated without Microscope | $30 | 60% | $12 |
Medium |
| Urine Test - Bacterial Culture | $97 | 60% | $39 |
Medium |
| Urine Test - Chlamydia | $183 | 60% | $73 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $183 | 60% | $73 |
Medium |
| Urine Test - Pregnancy | $29 | 60% | $12 |
Medium |
| X-Ray - Abdomen | $883 | 60% | $353 |
Medium |
| X-Ray - Ankle (outpatient) | $723 | 60% | $289 |
Medium |
| X-Ray - Chest (outpatient) | $842 | 60% | $337 |
Medium |
| X-Ray - Foot (outpatient) | $794 | 60% | $318 |
Medium |
| X-Ray - Hand | $836 | 60% | $334 |
Medium |
| X-Ray - Hip | $863 | 60% | $345 |
Medium |
| X-Ray - Knee (outpatient) | $835 | 60% | $334 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $838 | 60% | $335 |
Medium |
| X-Ray - Neck, Cervical Spine | $629 | 60% | $252 |
Medium |
| X-Ray - Pelvis | $837 | 60% | $335 |
Medium |
| X-Ray - Shoulder (outpatient) | $807 | 60% | $323 |
High |
| X-Ray - Spine (outpatient) | $914 | 60% | $365 |
Medium |
| X-Ray - Wrist (outpatient) | $897 | 60% | $359 |
Medium |
