| Bacterial Culture - Aerobic Isolates | $54 | N/A | $54 |
| Bacterial Culture - Swab | $172 | N/A | $172 |
| Blood Test - Blood Typing (ABO) | $55 | N/A | $55 |
| Blood Test - Blood Typing (Rh (D)) | $51 | N/A | $51 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $40 | N/A | $40 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $91 | N/A | $91 |
| Blood Test - Hepatitis B Surface Antibody Level | $75 | N/A | $75 |
| Blood Test - Hepatitis C Antibody Level | $195 | N/A | $195 |
| Blood Test - Iron Binding Capacity | $53 | N/A | $53 |
| Blood Test - Magnesium Level | $92 | N/A | $92 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $194 | N/A | $194 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $55 | N/A | $55 |
| Lab Test - Creatinine Level | $108 | N/A | $108 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $117 | N/A | $117 |
| Lab Test - Detection test for Human Papillomavirus (HPV) | $137 | N/A | $137 |
| Lab Test - Smear for Microorganism | $32 | N/A | $32 |
| Mammogram (outpatient) | $803 | N/A | $803 |
| Office Visit - Basic | $158 | N/A | $158 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $289 | N/A | $289 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $331 | N/A | $331 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $315 | N/A | $315 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $394 | N/A | $394 |
| Office Visit - Established Patient, High Complexity | $382 | N/A | $382 |
| Office Visit - Established Patient, Low Complexity | $163 | N/A | $163 |
| Office Visit - Established Patient, Moderate Complexity | $315 | N/A | $315 |
| Pap Test, automated screening and manual rescreening | $126 | N/A | $126 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $35 | N/A | $35 |
| Ultrasound - Pregnancy (outpatient) | $315 | N/A | $315 |
| Ultrasound - Pregnancy Follow-Up | $420 | N/A | $420 |
| Ultrasound - Transvaginal (non-maternity) | $742 | N/A | $742 |
| Urine Test - Automated without Microscope | $32 | N/A | $32 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $32 | N/A | $32 |
| Urine Test - Chlamydia | $170 | N/A | $170 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $170 | N/A | $170 |
| Urine Test - Pregnancy | $26 | N/A | $26 |
| Urine Test - Urinalysis, Manual Test | $16 | N/A | $16 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $81 | N/A | $81 |
