| Arthrocentesis (outpatient) | $518 | 50% | $259 |
| Bacterial Culture - Aerobic Isolates | $71 | 50% | $36 |
| Bacterial Culture - Swab | $80 | 50% | $40 |
| Blood Test - Basic Metabolic Panel | $71 | 50% | $36 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $85 | 50% | $43 |
| Blood Test - Cholesterol Test, Lipid Panel | $111 | 50% | $56 |
| Blood Test - Clotting Time | $41 | 50% | $21 |
| Blood Test - Coagulation Assessment | $50 | 50% | $25 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $58 | 50% | $29 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $87 | 50% | $44 |
| Blood Test - Comprehensive Metabolic Panel | $88 | 50% | $44 |
| Blood Test - Electrolytes Panel | $59 | 50% | $29 |
| Blood Test - Ferritin (Blood Protein) Level | $110 | 50% | $55 |
| Blood Test - Folic Acid Level | $123 | 50% | $61 |
| Blood Test - General Health Panel | $316 | 50% | $158 |
| Blood Test - Hepatic (Liver) Function Panel | $68 | 50% | $34 |
| Blood Test - Hepatitis C Antibody Level | $123 | 50% | $61 |
| Blood Test - Iron Level | $53 | 50% | $26 |
| Blood Test - LDL Cholesterol Level | $75 | 50% | $37 |
| Blood Test - Lipase (fat enzyme) Level | $54 | 50% | $27 |
| Blood Test - Pregnancy (Obstetric) Panel | $586 | 50% | $293 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $119 | 50% | $59 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $141 | 50% | $70 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $129 | 50% | $65 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $141 | 50% | $70 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $100 | 50% | $50 |
| Blood Test - Vitamin D-3 Level | $247 | 50% | $123 |
| Bone Density Scan (outpatient) | $518 | 50% | $259 |
| Colonoscopy - Diagnostic (outpatient) | $7,694 | 50% | $3,847 |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,448 | 50% | $1,724 |
| Detection test for Human Papillomavirus (HPV) | $228 | 50% | $114 |
| Emergency Department Visit - Low Complexity (outpatient) | $345 | 50% | $173 |
| Emergency Department Visit - Minor (outpatient) | $231 | 50% | $116 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $583 | 50% | $291 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $78 | 50% | $39 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $95 | 50% | $47 |
| Lab Test - Detection test for Influenza Virus | $32 | 50% | $16 |
| Lab Test - Smear for Microorganism | $42 | 50% | $21 |
| Mammogram (outpatient) | $1,182 | 50% | $591 |
| MRI - Back (outpatient) | $3,795 | 50% | $1,897 |
| MRI - Brain (outpatient) | $6,077 | 50% | $3,039 |
| MRI - Knee (outpatient) | $2,585 | 50% | $1,293 |
| Office Visit - Basic | $104 | 50% | $52 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $328 | 50% | $164 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $348 | 50% | $174 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $348 | 50% | $174 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $413 | 50% | $206 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $328 | 50% | $164 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $305 | 50% | $152 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $254 | 50% | $127 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $323 | 50% | $162 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $328 | 50% | $164 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $389 | 50% | $194 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $254 | 50% | $127 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $229 | 50% | $114 |
| Office Visit - Established Patient, High Complexity | $306 | 50% | $153 |
| Office Visit - Established Patient, Low Complexity | $148 | 50% | $74 |
| Office Visit - Established Patient, Moderate Complexity | $233 | 50% | $117 |
| Office Visit - New Patient, Low Complexity | $268 | 50% | $134 |
| Office Visit - New Patient, Minor | $177 | 50% | $89 |
| Office Visit - New Patient, Moderate Complexity | $347 | 50% | $173 |
| Pap Test | $175 | 50% | $88 |
| Physical Therapy - High Complexity Evaluation | $368 | 50% | $184 |
| Physical Therapy - Low Complexity Evaluation | $289 | 50% | $144 |
| Physical Therapy - Manual Therapy | $153 | 50% | $77 |
| Physical Therapy - Moderate Complexity Evaluation | $341 | 50% | $171 |
| Physical Therapy - Self-care or Home Management Training | $124 | 50% | $62 |
| Physical Therapy - Therapeutic Activities | $130 | 50% | $65 |
| Physical Therapy - Therapeutic Exercises | $138 | 50% | $69 |
| Physical Therapy - Ultrasound Therapy | $84 | 50% | $42 |
| Strep Test (Streptococcus, group A) | $100 | 50% | $50 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $55 | 50% | $27 |
| Ultrasound - Abdominal, Complete | $869 | 50% | $435 |
| Ultrasound - Abdominal, Limited | $673 | 50% | $337 |
| Ultrasound - Breast (outpatient) | $1,634 | 50% | $817 |
| Ultrasound - Head and Neck | $984 | 50% | $492 |
| Ultrasound - Transvaginal (non-maternity) | $1,741 | 50% | $870 |
| Urine Test - Automated with Microscope Examination | $45 | 50% | $23 |
| Urine Test - Automated without Microscope | $18 | 50% | $9 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $65 | 50% | $33 |
| Urine Test - Chlamydia | $216 | 50% | $108 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $216 | 50% | $108 |
| Urine Test - Microalbumin (Protein) Level | $48 | 50% | $24 |
| Urine Test - Pregnancy | $56 | 50% | $28 |
| Urine Test - Urinalysis, Manual Test | $24 | 50% | $12 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $219 | 50% | $110 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $98 | 50% | $49 |
| X-Ray - Abdomen | $377 | 50% | $189 |
| X-Ray - Ankle (outpatient) | $391 | 50% | $196 |
| X-Ray - Chest (outpatient) | $461 | 50% | $230 |
| X-Ray - Foot (outpatient) | $567 | 50% | $284 |
| X-Ray - Hand | $790 | 50% | $395 |
| X-Ray - Hip | $722 | 50% | $361 |
| X-Ray - Knee (outpatient) | $509 | 50% | $254 |
| X-Ray - Shoulder (outpatient) | $568 | 50% | $284 |
| X-Ray - Spine (outpatient) | $475 | 50% | $237 |
| X-Ray - Wrist (outpatient) | $594 | 50% | $297 |
