| Arthrocentesis (outpatient) | $848 | 0% | $848 |
| Bacterial Culture - Swab | $187 | 0% | $187 |
| Biopsy - Punch Biopsy of Skin | $1,309 | 0% | $1,309 |
| Biopsy - Tangential Biopsy of Skin | $1,068 | 0% | $1,068 |
| Blood Test - Basic Metabolic Panel | $109 | 0% | $109 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $109 | 0% | $109 |
| Blood Test - Cholesterol Test, Lipid Panel | $95 | 0% | $95 |
| Blood Test - Clotting Time | $62 | 0% | $62 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $78 | 0% | $78 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $70 | 0% | $70 |
| Blood Test - Comprehensive Metabolic Panel | $54 | 0% | $54 |
| Blood Test - General Health Panel | $199 | 0% | $199 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $112 | 0% | $112 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $95 | 0% | $95 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $111 | 0% | $111 |
| Blood Test - Vitamin D-3 Level | $287 | 0% | $287 |
| Bone Density Scan (outpatient) | $681 | 0% | $681 |
| CT Scan - Abdomen and Pelvis, with Contrast | $2,625 | 0% | $2,625 |
| CT Scan - Chest, with Contrast (outpatient) | $2,172 | 0% | $2,172 |
| Destruction of Lesion (outpatient) | $546 | 0% | $546 |
| Destruction of Lesions, up to 14 | $585 | 0% | $585 |
| Detection test for Human Papillomavirus (HPV) | $195 | 0% | $195 |
| Electrocardiogram (ECG or EKG) | $551 | 0% | $551 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $114 | 0% | $114 |
| Lab Test - Detection test for Influenza Virus | $35 | 0% | $35 |
| Laryngoscopy - Diagnostic | $1,179 | 0% | $1,179 |
| Mammogram (outpatient) | $523 | 0% | $523 |
| MRI - Back (outpatient) | $3,379 | 0% | $3,379 |
| MRI - Brain (outpatient) | $7,083 | 0% | $7,083 |
| MRI - Knee (outpatient) | $3,140 | 0% | $3,140 |
| MRI - Pelvis (outpatient) | $6,393 | 0% | $6,393 |
| Nasal Endoscopy - Diagnostic | $1,290 | 0% | $1,290 |
| Office Visit - Basic | $162 | 0% | $162 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $406 | 0% | $406 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $480 | 0% | $480 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $461 | 0% | $461 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $521 | 0% | $521 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $408 | 0% | $408 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $368 | 0% | $368 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $310 | 0% | $310 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $370 | 0% | $370 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $403 | 0% | $403 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $440 | 0% | $440 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $310 | 0% | $310 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $289 | 0% | $289 |
| Office Visit - Established Patient, High Complexity | $492 | 0% | $492 |
| Office Visit - Established Patient, Low Complexity | $226 | 0% | $226 |
| Office Visit - Established Patient, Moderate Complexity | $344 | 0% | $344 |
| Office Visit - New Patient, Low Complexity | $344 | 0% | $344 |
| Office Visit - New Patient, Minor | $260 | 0% | $260 |
| Office Visit - New Patient, Moderate Complexity | $520 | 0% | $520 |
| Pap Test | $236 | 0% | $236 |
| Strep Test (Streptococcus, group A) | $103 | 0% | $103 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $117 | 0% | $117 |
| Ultrasound - Breast (outpatient) | $831 | 0% | $831 |
| Ultrasound - Pelvic (outpatient) | $595 | 0% | $595 |
| Ultrasound - Pregnancy (outpatient) | $716 | 0% | $716 |
| Ultrasound - Pregnancy Follow-Up | $490 | 0% | $490 |
| Ultrasound - Transvaginal (non-maternity) | $572 | 0% | $572 |
| Urine Test - Automated with Microscope Examination | $112 | 0% | $112 |
| Urine Test - Automated without Microscope | $17 | 0% | $17 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $87 | 0% | $87 |
| Urine Test - Chlamydia | $133 | 0% | $133 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $133 | 0% | $133 |
| Urine Test - Microalbumin (Protein) Level | $69 | 0% | $69 |
| Urine Test - Pregnancy | $59 | 0% | $59 |
| Urine Test - Urinalysis, Manual Test | $55 | 0% | $55 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $624 | 0% | $624 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $141 | 0% | $141 |
| X-Ray - Chest (outpatient) | $581 | 0% | $581 |
| X-Ray - Foot (outpatient) | $620 | 0% | $620 |
| X-Ray - Knee (outpatient) | $460 | 0% | $460 |
| X-Ray - Shoulder (outpatient) | $636 | 0% | $636 |
