| Arthrocentesis (outpatient) | $819 | 0% | $819 |
| Bacterial Culture - Aerobic Isolates | $101 | 0% | $101 |
| Bacterial Culture - Swab | $187 | 0% | $187 |
| Biopsy - Punch Biopsy of Skin | $2,179 | 0% | $2,179 |
| Biopsy - Tangential Biopsy of Skin | $1,469 | 0% | $1,469 |
| Blood Test - Basic Metabolic Panel | $48 | 0% | $48 |
| 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 - Coagulation Assessment | $51 | 0% | $51 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $67 | 0% | $67 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $70 | 0% | $70 |
| Blood Test - Comprehensive Metabolic Panel | $62 | 0% | $62 |
| Blood Test - Ferritin (Blood Protein) Level | $78 | 0% | $78 |
| Blood Test - Folic Acid Level | $101 | 0% | $101 |
| Blood Test - General Health Panel | $212 | 0% | $212 |
| Blood Test - Hepatic (Liver) Function Panel | $54 | 0% | $54 |
| Blood Test - Hepatitis C Antibody Level | $216 | 0% | $216 |
| Blood Test - Iron Level | $28 | 0% | $28 |
| Blood Test - Lipase (fat enzyme) Level | $30 | 0% | $30 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $117 | 0% | $117 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $95 | 0% | $95 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $111 | 0% | $111 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $85 | 0% | $85 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $97 | 0% | $97 |
| Blood Test - Vitamin D-3 Level | $186 | 0% | $186 |
| Bone Density Scan (outpatient) | $779 | 0% | $779 |
| Chiropractic Manipulative Treatment - Spinal, 1-2 Regions | $48 | 0% | $48 |
| Chiropractic Manipulative Treatment - Spinal, 3-4 Regions | $69 | 0% | $69 |
| CT Scan - Abdomen and Pelvis, with Contrast | $2,739 | 0% | $2,739 |
| CT Scan - Chest, with Contrast (outpatient) | $3,081 | 0% | $3,081 |
| Destruction of Lesion (outpatient) | $574 | 0% | $574 |
| Destruction of Lesions, up to 14 | $681 | 0% | $681 |
| Detection test for Human Papillomavirus (HPV) | $188 | 0% | $188 |
| Electrocardiogram (ECG or EKG) | $869 | 0% | $869 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $152 | 0% | $152 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $190 | 0% | $190 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $188 | 0% | $188 |
| Lab Test - Detection test for Influenza Virus | $85 | 0% | $85 |
| Mammogram (outpatient) | $1,025 | 0% | $1,025 |
| MRI - Back (outpatient) | $3,468 | 0% | $3,468 |
| MRI - Brain (outpatient) | $6,820 | 0% | $6,820 |
| MRI - Knee (outpatient) | $3,140 | 0% | $3,140 |
| MRI - Pelvis (outpatient) | $6,295 | 0% | $6,295 |
| Office Visit - Basic | $158 | 0% | $158 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $442 | 0% | $442 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $516 | 0% | $516 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $407 | 0% | $407 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $376 | 0% | $376 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $354 | 0% | $354 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $387 | 0% | $387 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $387 | 0% | $387 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $422 | 0% | $422 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $354 | 0% | $354 |
| Office Visit - Established Patient, High Complexity | $482 | 0% | $482 |
| Office Visit - Established Patient, Low Complexity | $226 | 0% | $226 |
| Office Visit - Established Patient, Moderate Complexity | $357 | 0% | $357 |
| Office Visit - New Patient, Low Complexity | $163 | 0% | $163 |
| Office Visit - New Patient, Minor | $253 | 0% | $253 |
| Office Visit - New Patient, Moderate Complexity | $520 | 0% | $520 |
| Pap Test | $236 | 0% | $236 |
| Physical Therapy - Moderate Complexity Evaluation | $309 | 0% | $309 |
| Physical Therapy - Therapeutic Exercises | $138 | 0% | $138 |
| Psychiatric Diagnostic Evaluation | $200 | 0% | $200 |
| Psychotherapy - 30 Minutes | $161 | 0% | $161 |
| Psychotherapy - 45 Minutes | $179 | 0% | $179 |
| Psychotherapy - 60 Minutes | $189 | 0% | $189 |
| Psychotherapy - Family Session | $135 | 0% | $135 |
| Psychotherapy - Group Session | $129 | 0% | $129 |
| Strep Test (Streptococcus, group A) | $103 | 0% | $103 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $191 | 0% | $191 |
| Ultrasound - Breast (outpatient) | $922 | 0% | $922 |
| Ultrasound - Pelvic (outpatient) | $656 | 0% | $656 |
| Ultrasound - Pregnancy (outpatient) | $884 | 0% | $884 |
| Ultrasound - Pregnancy Follow-Up | $956 | 0% | $956 |
| Ultrasound - Transvaginal (non-maternity) | $683 | 0% | $683 |
| Urine Test - Automated with Microscope Examination | $171 | 0% | $171 |
| Urine Test - Automated without Microscope | $109 | 0% | $109 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $90 | 0% | $90 |
| Urine Test - Chlamydia | $158 | 0% | $158 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $158 | 0% | $158 |
| Urine Test - Microalbumin (Protein) Level | $69 | 0% | $69 |
| Urine Test - Pregnancy | $59 | 0% | $59 |
| Urine Test - Urinalysis, Manual Test | $21 | 0% | $21 |
| 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) | $593 | 0% | $593 |
| X-Ray - Shoulder (outpatient) | $812 | 0% | $812 |
| X-Ray - Wrist (outpatient) | $690 | 0% | $690 |
