| Arthrocentesis (outpatient) | $1,002 | 60% | $401 | 
High |
| Bacterial Culture Swab | $141 | 60% | $56 | 
Medium |
| Biopsy - Breast | $3,731 | 60% | $1,492 |
Medium |
| Biopsy - Endometrial (Uterus) | $1,434 | 60% | $574 |
Medium |
| Biopsy - Skin Lesion | $1,173 | 60% | $469 |
Medium |
| Blood Test - Basic Metabolic Panel | $97 | 60% | $39 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $112 | 60% | $45 |
Medium |
| Blood Test - Cholesterol Test, Lipid Panel | $128 | 60% | $51 |
Medium |
| Blood Test - Clotting Time | $68 | 60% | $27 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $79 | 60% | $32 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $97 | 60% | $39 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $116 | 60% | $46 |
Medium |
| Blood Test - Electrolytes Panel | $119 | 60% | $47 |
Medium |
| Blood Test - Folic Acid Level | $179 | 60% | $71 |
Medium |
| Blood Test - General Health Panel | $376 | 60% | $150 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $100 | 60% | $40 |
Medium |
| Blood Test - Hepatitis C Antibody Level | $244 | 60% | $97 |
Medium |
| Blood Test - LDL Cholesterol Level | $83 | 60% | $33 |
Medium |
| Blood Test - Lipase (fat enzyme) Level | $118 | 60% | $47 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $179 | 60% | $71 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $97 | 60% | $39 |
Medium |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $164 | 60% | $66 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $163 | 60% | $65 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $179 | 60% | $71 |
Medium |
| Blood Test - Vitamin D-3 Level | $251 | 60% | $100 |
Medium |
| Bone Density Scan (outpatient) | $407 | 60% | $163 |
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) | $4,951 | 60% | $1,980 |
High |
| Colonoscopy - With Biopsy (outpatient) | $3,810 | 60% | $1,524 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $6,336 | 60% | $2,534 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $7,830 | 60% | $3,132 |
High |
| CT Scan - Chest, with Contrast (outpatient) | $4,481 | 60% | $1,792 |
High |
| CT Scan - Head/Brain, without Contrast | $2,777 | 60% | $1,111 |
Medium |
| Cystoscopy | $1,777 | 60% | $711 |
High |
| Destruction of Lesion (outpatient) | $507 | 60% | $203 |
Medium |
| Destruction of Lesions, up to 14 | $586 | 60% | $234 |
Medium |
| Detection Test for Human Papillomavirus (HPV) | $156 | 60% | $63 |
Medium |
| Electrocardiogram (ECG or EKG) | $784 | 60% | $314 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $611 | 60% | $244 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $353 | 60% | $141 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,045 | 60% | $418 |
Medium |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $141 | 60% | $56 |
Medium |
| Fetal Non-Stress Test | $895 | 60% | $358 |
Medium |
| Gall Bladder Surgery (outpatient) | $22,624 | 60% | $9,050 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $22,058 | 60% | $8,823 |
Medium |
| Kidney Stone Removal (outpatient) | $20,665 | 60% | $8,266 |
High |
| Mammogram (outpatient) | $776 | 60% | $311 |
Medium |
| MRI - Back (outpatient) | $2,418 | 60% | $967 |
Medium |
| MRI - Brain (outpatient) | $6,765 | 60% | $2,706 |
High |
| MRI - Knee (outpatient) | $2,157 | 60% | $863 |
Medium |
| MRI - Pelvis (outpatient) | $6,844 | 60% | $2,738 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $4,640 | 60% | $1,856 |
High |
| Myocardial Imaging (outpatient) | $6,847 | 60% | $2,739 |
Medium |
| Office Visit - Basic | $165 | 60% | $66 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $294 | 60% | $118 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $348 | 60% | $139 |
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 | $432 | 60% | $173 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $294 | 60% | $118 |
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 | $265 | 60% | $106 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $301 | 60% | $121 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $311 | 60% | $124 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $352 | 60% | $141 |
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 | $225 | 60% | $90 |
Medium |
| Office Visit - Established Patient, Moderate Complexity | $322 | 60% | $129 |
Medium |
| Office Visit - New Patient, Low Complexity | $301 | 60% | $121 |
Medium |
| Office Visit - New Patient, Minor | $263 | 60% | $105 |
Medium |
| Pap Test | $163 | 60% | $65 |
Medium |
| Physical Therapy - Application of Hot or Cold Pack | $27 | 60% | $11 |
Medium |
| Physical Therapy - Application of Mechanical Traction | $47 | 60% | $19 |
Medium |
| Physical Therapy - High Complexity Evaluation | $374 | 60% | $150 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $259 | 60% | $104 |
Medium |
| Physical Therapy - Manual Therapy | $101 | 60% | $40 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $286 | 60% | $114 |
Medium |
| Physical Therapy - Neuromuscular Reeducation | $98 | 60% | $39 |
Medium |
| Physical Therapy - Re-Evaluation | $133 | 60% | $53 |
Medium |
| Physical Therapy - Self-care or Home Management Training | $109 | 60% | $44 |
Medium |
| Physical Therapy - Therapeutic Activities | $101 | 60% | $40 |
Medium |
| Physical Therapy - Therapeutic Exercises | $101 | 60% | $40 |
Medium |
| Physical Therapy - Therapeutic Massage | $22 | 60% | $9 |
Medium |
| Physical Therapy - Ultrasound Therapy | $98 | 60% | $39 |
Medium |
| Psychiatric Diagnostic Evaluation | $210 | 60% | $84 |
Medium |
| Psychotherapy - 45 Minutes | $131 | 60% | $53 |
Medium |
| Psychotherapy - 60 Minutes | $163 | 60% | $65 |
Medium |
| Psychotherapy - Group Session | $177 | 60% | $71 |
Medium |
| Strep Test (Streptococcus, group A) | $75 | 60% | $30 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $102 | 60% | $41 |
Medium |
| Tonsillectomy with Adenoidectomy (outpatient) | $7,699 | 60% | $3,080 |
High |
| Ultrasound - Abdominal, Complete | $1,632 | 60% | $653 |
Medium |
| Ultrasound - Abdominal, Limited | $1,183 | 60% | $473 |
Medium |
| Ultrasound - Breast (outpatient) | $1,054 | 60% | $421 |
Medium |
| Ultrasound - Head and Neck | $1,162 | 60% | $465 |
Medium |
| Ultrasound - Pelvic (outpatient) | $552 | 60% | $221 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $337 | 60% | $135 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $459 | 60% | $184 |
Medium |
| Ultrasound - Transvaginal (non-maternity) | $960 | 60% | $384 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $4,700 | 60% | $1,880 |
High |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,121 | 60% | $2,048 |
Medium |
| Urine Capacity Measurement | $495 | 60% | $198 |
Medium |
| Urine Test - Automated with Microscope Examination | $110 | 60% | $44 |
Medium |
| Urine Test - Automated without Microscope | $30 | 60% | $12 |
Medium |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $102 | 60% | $41 |
Medium |
| Urine Test - Chlamydia | $192 | 60% | $77 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $192 | 60% | $77 |
Medium |
| Urine Test - Pregnancy | $30 | 60% | $12 |
Medium |
| X-Ray - Abdomen | $837 | 60% | $335 |
Medium |
| X-Ray - Ankle (outpatient) | $771 | 60% | $308 |
High |
| X-Ray - Chest (outpatient) | $945 | 60% | $378 |
High |
| X-Ray - Foot (outpatient) | $822 | 60% | $329 |
Medium |
| X-Ray - Hand | $929 | 60% | $371 |
High |
| X-Ray - Hip | $896 | 60% | $358 |
High |
| X-Ray - Knee (outpatient) | $812 | 60% | $325 |
Medium |
| X-Ray - Neck, Cervical Spine | $831 | 60% | $332 |
High |
| X-Ray - Shoulder (outpatient) | $896 | 60% | $358 |
Medium |
| X-Ray - Spine (outpatient) | $954 | 60% | $381 |
Medium |
| X-Ray - Wrist (outpatient) | $842 | 60% | $337 |
Medium |
