| Arthrocentesis (outpatient) | $1,096 | 60% | $438 |
| Bacterial Culture - Aerobic Isolates | $89 | 60% | $36 |
| Bacterial Culture - Swab | $141 | 60% | $56 |
| Biopsy - Breast | $3,577 | 60% | $1,431 |
| Biopsy - Endometrial (Uterus) | $1,531 | 60% | $612 |
| Biopsy - Punch Biopsy of Skin | $1,156 | 60% | $462 |
| Biopsy - Tangential Biopsy of Skin | $1,046 | 60% | $419 |
| Blood Test - Basic Metabolic Panel | $97 | 60% | $39 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $112 | 60% | $45 |
| Blood Test - Cholesterol Test, Lipid Panel | $128 | 60% | $51 |
| Blood Test - Clotting Time | $71 | 60% | $29 |
| Blood Test - Coagulation Assessment | $107 | 60% | $43 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $79 | 60% | $32 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $97 | 60% | $39 |
| Blood Test - Comprehensive Metabolic Panel | $116 | 60% | $46 |
| Blood Test - Electrolytes Panel | $122 | 60% | $49 |
| Blood Test - Ferritin (Blood Protein) Level | $179 | 60% | $71 |
| Blood Test - Folic Acid Level | $179 | 60% | $71 |
| Blood Test - General Health Panel | $376 | 60% | $150 |
| Blood Test - Hepatic (Liver) Function Panel | $100 | 60% | $40 |
| Blood Test - Hepatitis C Antibody Level | $256 | 60% | $102 |
| Blood Test - Iron Level | $63 | 60% | $25 |
| Blood Test - LDL Cholesterol Level | $83 | 60% | $33 |
| Blood Test - Lipase (fat enzyme) Level | $118 | 60% | $47 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $179 | 60% | $71 |
| Blood Test - Renal (Kidney) Function Panel | $97 | 60% | $39 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $164 | 60% | $66 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $163 | 60% | $65 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $204 | 60% | $81 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $179 | 60% | $71 |
| Blood Test - Vitamin D-3 Level | $251 | 60% | $100 |
| Bone Density Scan (outpatient) | $416 | 60% | $166 |
| Chiropractic Manipulative Treatment - Spinal, 1-2 Regions | $68 | 60% | $27 |
| Chiropractic Manipulative Treatment - Spinal, 3-4 Regions | $74 | 60% | $29 |
| Chiropractic Manipulative Treatment - Spinal, 5 Regions | $63 | 60% | $25 |
| Colonoscopy - Diagnostic (outpatient) | $5,046 | 60% | $2,018 |
| Colonoscopy - With Biopsy (outpatient) | $5,056 | 60% | $2,022 |
| Colonoscopy - With Polyp Removal (outpatient) | $6,481 | 60% | $2,592 |
| CT Scan - Abdomen and Pelvis, with Contrast | $8,196 | 60% | $3,278 |
| CT Scan - Chest, with Contrast (outpatient) | $4,485 | 60% | $1,794 |
| CT Scan - Head/Brain, without Contrast | $2,936 | 60% | $1,174 |
| Cystoscopy | $1,792 | 60% | $717 |
| Destruction of Lesion (outpatient) | $544 | 60% | $218 |
| Destruction of Lesions, up to 14 | $586 | 60% | $234 |
| Detection test for Human Papillomavirus (HPV) | $156 | 60% | $63 |
| Electrocardiogram (ECG or EKG) | $651 | 60% | $260 |
| Emergency Department Visit - Low Complexity (outpatient) | $611 | 60% | $244 |
| Emergency Department Visit - Minor (outpatient) | $371 | 60% | $148 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,045 | 60% | $418 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $141 | 60% | $56 |
| Fetal Non-Stress Test | $968 | 60% | $387 |
| Gall Bladder Surgery (outpatient) | $22,456 | 60% | $8,982 |
| Hernia Repair - Laparoscopic (outpatient) | $20,994 | 60% | $8,398 |
| Kidney Stone Removal (outpatient) | $20,467 | 60% | $8,187 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $215 | 60% | $86 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $103 | 60% | $41 |
| Lab Test - Detection test for Influenza Virus | $35 | 60% | $14 |
| Lab Test - Smear for Microorganism | $89 | 60% | $36 |
| Mammogram (outpatient) | $776 | 60% | $311 |
| MRI - Back (outpatient) | $2,423 | 60% | $969 |
| MRI - Brain (outpatient) | $7,019 | 60% | $2,808 |
| MRI - Knee (outpatient) | $2,157 | 60% | $863 |
| MRI - Pelvis (outpatient) | $7,149 | 60% | $2,859 |
| MRI - Shoulder, Elbow, or Wrist | $4,975 | 60% | $1,990 |
| Myocardial Imaging (outpatient) | $7,771 | 60% | $3,108 |
| Office Visit - Basic | $165 | 60% | $66 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $221 | 60% | $88 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $352 | 60% | $141 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $352 | 60% | $141 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $432 | 60% | $173 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $302 | 60% | $121 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $273 | 60% | $109 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $273 | 60% | $109 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $311 | 60% | $124 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $311 | 60% | $124 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $352 | 60% | $141 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $273 | 60% | $109 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $233 | 60% | $93 |
| Office Visit - Established Patient, High Complexity | $456 | 60% | $182 |
| Office Visit - Established Patient, Low Complexity | $225 | 60% | $90 |
| Office Visit - Established Patient, Moderate Complexity | $322 | 60% | $129 |
| Office Visit - New Patient, Low Complexity | $310 | 60% | $124 |
| Office Visit - New Patient, Minor | $263 | 60% | $105 |
| Office Visit - New Patient, Moderate Complexity | $539 | 60% | $215 |
| Pap Test | $163 | 60% | $65 |
| Physical Therapy - Application of Hot or Cold Pack | $27 | 60% | $11 |
| Physical Therapy - Application of Mechanical Traction | $47 | 60% | $19 |
| Physical Therapy - High Complexity Evaluation | $385 | 60% | $154 |
| Physical Therapy - Low Complexity Evaluation | $268 | 60% | $107 |
| Physical Therapy - Manual Electrical Stimulation Therapy, 15 minutes | $47 | 60% | $19 |
| Physical Therapy - Manual Therapy | $101 | 60% | $40 |
| Physical Therapy - Moderate Complexity Evaluation | $286 | 60% | $114 |
| Physical Therapy - Neuromuscular Reeducation | $101 | 60% | $40 |
| Physical Therapy - Re-Evaluation | $133 | 60% | $53 |
| Physical Therapy - Self-care or Home Management Training | $112 | 60% | $45 |
| Physical Therapy - Therapeutic Activities | $101 | 60% | $40 |
| Physical Therapy - Therapeutic Exercises | $101 | 60% | $40 |
| Physical Therapy - Therapeutic Massage | $23 | 60% | $9 |
| Physical Therapy - Ultrasound Therapy | $101 | 60% | $40 |
| Psychiatric Diagnostic Evaluation | $210 | 60% | $84 |
| Psychotherapy - 45 Minutes | $131 | 60% | $53 |
| Psychotherapy - 60 Minutes | $163 | 60% | $65 |
| Psychotherapy - Group Session | $177 | 60% | $71 |
| Strep Test (Streptococcus, group A) | $75 | 60% | $30 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $102 | 60% | $41 |
| Ultrasound - Abdominal, Complete | $1,635 | 60% | $654 |
| Ultrasound - Abdominal, Limited | $1,185 | 60% | $474 |
| Ultrasound - Breast (outpatient) | $1,054 | 60% | $421 |
| Ultrasound - Head and Neck | $1,164 | 60% | $466 |
| Ultrasound - Pelvic (outpatient) | $619 | 60% | $248 |
| Ultrasound - Pregnancy (outpatient) | $337 | 60% | $135 |
| Ultrasound - Pregnancy Follow-Up | $459 | 60% | $184 |
| Ultrasound - Transvaginal (non-maternity) | $1,004 | 60% | $402 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $4,408 | 60% | $1,763 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $4,987 | 60% | $1,995 |
| Urine Capacity Measurement | $513 | 60% | $205 |
| Urine Test - Automated with Microscope Examination | $110 | 60% | $44 |
| Urine Test - Automated without Microscope | $32 | 60% | $13 |
| Urine Test - Bacterial Culture | $12 | 60% | $5 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $102 | 60% | $41 |
| Urine Test - Chlamydia | $192 | 60% | $77 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $192 | 60% | $77 |
| Urine Test - Microalbumin (Protein) Level | $116 | 60% | $46 |
| Urine Test - Pregnancy | $30 | 60% | $12 |
| Urine Test - Urinalysis, Manual Test | $8 | 60% | $3 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $263 | 60% | $105 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $83 | 60% | $33 |
| X-Ray - Abdomen | $793 | 60% | $317 |
| X-Ray - Ankle (outpatient) | $843 | 60% | $337 |
| X-Ray - Chest (outpatient) | $951 | 60% | $381 |
| X-Ray - Foot (outpatient) | $924 | 60% | $370 |
| X-Ray - Hand | $966 | 60% | $386 |
| X-Ray - Hip | $950 | 60% | $380 |
| X-Ray - Knee (outpatient) | $717 | 60% | $287 |
| X-Ray - Neck, Cervical Spine | $939 | 60% | $375 |
| X-Ray - Shoulder (outpatient) | $913 | 60% | $365 |
| X-Ray - Spine (outpatient) | $995 | 60% | $398 |
| X-Ray - Wrist (outpatient) | $929 | 60% | $371 |
