| Arthrocentesis (outpatient) | $411 | 0% | $411 |
| Bacterial Culture - Aerobic Isolates | $16 | 0% | $16 |
| Bacterial Culture - Swab | $17 | 0% | $17 |
| Blood Test - Basic Metabolic Panel | $16 | 0% | $16 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $19 | 0% | $19 |
| Blood Test - Cholesterol Test, Lipid Panel | $26 | 0% | $26 |
| Blood Test - Clotting Time | $7 | 0% | $7 |
| Blood Test - Coagulation Assessment | $12 | 0% | $12 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $13 | 0% | $13 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $15 | 0% | $15 |
| Blood Test - Comprehensive Metabolic Panel | $20 | 0% | $20 |
| Blood Test - Electrolytes Panel | $14 | 0% | $14 |
| Blood Test - Ferritin (Blood Protein) Level | $26 | 0% | $26 |
| Blood Test - Folic Acid Level | $28 | 0% | $28 |
| Blood Test - General Health Panel | $67 | 0% | $67 |
| Blood Test - Hepatic (Liver) Function Panel | $16 | 0% | $16 |
| Blood Test - Hepatitis C Antibody Level | $25 | 0% | $25 |
| Blood Test - Iron Level | $13 | 0% | $13 |
| Blood Test - Lipase (fat enzyme) Level | $14 | 0% | $14 |
| Blood Test - Pregnancy (Obstetric) Panel | $191 | 0% | $191 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $28 | 0% | $28 |
| Blood Test - Renal (Kidney) Function Panel | $17 | 0% | $17 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $33 | 0% | $33 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $17 | 0% | $17 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $32 | 0% | $32 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $23 | 0% | $23 |
| Blood Test - Vitamin D-3 Level | $56 | 0% | $56 |
| Bone Density Scan (outpatient) | $743 | 0% | $743 |
| CT Scan - Abdomen and Pelvis, with Contrast | $2,067 | 0% | $2,067 |
| CT Scan - Chest, with Contrast (outpatient) | $2,459 | 0% | $2,459 |
| Destruction of Lesion (outpatient) | $447 | 0% | $447 |
| Detection test for Human Papillomavirus (HPV) | $59 | 0% | $59 |
| Electrocardiogram (ECG or EKG) | $416 | 0% | $416 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $17 | 0% | $17 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $19 | 0% | $19 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $42 | 0% | $42 |
| Lab Test - Detection test for Influenza Virus | $21 | 0% | $21 |
| Lab Test - Smear for Microorganism | $8 | 0% | $8 |
| Laryngoscopy - Diagnostic | $548 | 0% | $548 |
| Mammogram (outpatient) | $761 | 0% | $761 |
| MRI - Back (outpatient) | $2,844 | 0% | $2,844 |
| MRI - Brain (outpatient) | $4,493 | 0% | $4,493 |
| MRI - Knee (outpatient) | $2,856 | 0% | $2,856 |
| MRI - Pelvis (outpatient) | $4,476 | 0% | $4,476 |
| Nasal Endoscopy - Diagnostic | $636 | 0% | $636 |
| Office Visit - Basic | $97 | 0% | $97 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $273 | 0% | $273 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $320 | 0% | $320 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $311 | 0% | $311 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $361 | 0% | $361 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $284 | 0% | $284 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $261 | 0% | $261 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $251 | 0% | $251 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $274 | 0% | $274 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $279 | 0% | $279 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $298 | 0% | $298 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $250 | 0% | $250 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $234 | 0% | $234 |
| Office Visit - Established Patient, High Complexity | $317 | 0% | $317 |
| Office Visit - Established Patient, Low Complexity | $160 | 0% | $160 |
| Office Visit - Established Patient, Moderate Complexity | $235 | 0% | $235 |
| Office Visit - New Patient, Low Complexity | $236 | 0% | $236 |
| Office Visit - New Patient, Minor | $165 | 0% | $165 |
| Office Visit - New Patient, Moderate Complexity | $359 | 0% | $359 |
| Pap Test | $40 | 0% | $40 |
| Physical Therapy - Low Complexity Evaluation | $137 | 0% | $137 |
| Physical Therapy - Manual Electrical Stimulation Therapy, 15 minutes | $37 | 0% | $37 |
| Physical Therapy - Manual Therapy | $116 | 0% | $116 |
| Physical Therapy - Moderate Complexity Evaluation | $147 | 0% | $147 |
| Physical Therapy - Neuromuscular Reeducation | $53 | 0% | $53 |
| Physical Therapy - Re-Evaluation | $79 | 0% | $79 |
| Physical Therapy - Therapeutic Activities | $53 | 0% | $53 |
| Physical Therapy - Therapeutic Exercises | $95 | 0% | $95 |
| Physical Therapy - Ultrasound Therapy | $47 | 0% | $47 |
| Strep Test (Streptococcus, group A) | $22 | 0% | $22 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $12 | 0% | $12 |
| Ultrasound - Breast (outpatient) | $868 | 0% | $868 |
| Urine Capacity Measurement | $216 | 0% | $216 |
| Urine Test - Automated with Microscope Examination | $6 | 0% | $6 |
| Urine Test - Automated without Microscope | $3 | 0% | $3 |
| Urine Test - Bacterial Culture | $8 | 0% | $8 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $13 | 0% | $13 |
| Urine Test - Chlamydia | $48 | 0% | $48 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $49 | 0% | $49 |
| Urine Test - Microalbumin (Protein) Level | $11 | 0% | $11 |
| Urine Test - Pregnancy | $13 | 0% | $13 |
| Urine Test - Urinalysis, Manual Test | $6 | 0% | $6 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $397 | 0% | $397 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $64 | 0% | $64 |
| X-Ray - Ankle (outpatient) | $341 | 0% | $341 |
| X-Ray - Chest (outpatient) | $438 | 0% | $438 |
| X-Ray - Foot (outpatient) | $340 | 0% | $340 |
| X-Ray - Hand | $608 | 0% | $608 |
| X-Ray - Hip | $240 | 0% | $240 |
| X-Ray - Knee (outpatient) | $202 | 0% | $202 |
| X-Ray - Spine (outpatient) | $410 | 0% | $410 |
| X-Ray - Wrist (outpatient) | $498 | 0% | $498 |
