| Arthrocentesis (outpatient) | $1,466 | 89% | $161 |
| Bacterial Culture - Swab | $167 | 89% | $18 |
| Biopsy - Breast | $12,699 | 89% | $1,397 |
| Blood Test - Clotting Time | $89 | 89% | $10 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $138 | 89% | $15 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $33 | 89% | $4 |
| Blood Test - Comprehensive Metabolic Panel | $205 | 89% | $23 |
| Blood Test - Folic Acid Level | $182 | 89% | $20 |
| Blood Test - Hepatic (Liver) Function Panel | $139 | 89% | $15 |
| Blood Test - Hepatitis C Antibody Level | $205 | 89% | $23 |
| Blood Test - Lipase (fat enzyme) Level | $153 | 89% | $17 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $174 | 89% | $19 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $204 | 89% | $22 |
| Bone Density Scan (outpatient) | $1,136 | 89% | $125 |
| Colonoscopy - Diagnostic (outpatient) | $5,433 | 89% | $598 |
| Colonoscopy - With Biopsy (outpatient) | $7,132 | 89% | $785 |
| Colonoscopy - With Polyp Removal (outpatient) | $6,920 | 89% | $761 |
| CT Scan - Abdomen and Pelvis, with Contrast | $5,174 | 89% | $569 |
| CT Scan - Chest, with Contrast (outpatient) | $4,867 | 89% | $535 |
| CT Scan - Head/Brain, without Contrast | $4,323 | 89% | $475 |
| Cystoscopy | $2,991 | 89% | $329 |
| Detection test for Human Papillomavirus (HPV) | $210 | 89% | $23 |
| Emergency Department Visit - Low Complexity (outpatient) | $1,227 | 89% | $135 |
| Emergency Department Visit - Minor (outpatient) | $762 | 89% | $84 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $2,982 | 89% | $328 |
| Fetal Non-Stress Test | $1,365 | 89% | $150 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $205 | 89% | $23 |
| Lab Test - Smear for Microorganism | $76 | 89% | $8 |
| Laryngoscopy - Diagnostic | $478 | 89% | $53 |
| Mammogram (outpatient) | $1,046 | 89% | $115 |
| MRI - Back (outpatient) | $5,057 | 89% | $556 |
| MRI - Brain (outpatient) | $8,067 | 89% | $887 |
| Nasal Endoscopy - Diagnostic | $683 | 89% | $75 |
| Office Visit - Basic | $89 | 89% | $10 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $234 | 89% | $26 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $234 | 89% | $26 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $272 | 89% | $30 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $205 | 89% | $23 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $205 | 89% | $23 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $224 | 89% | $25 |
| Office Visit - Established Patient, High Complexity | $292 | 89% | $32 |
| Office Visit - Established Patient, Low Complexity | $147 | 89% | $16 |
| Office Visit - Established Patient, Moderate Complexity | $217 | 89% | $24 |
| Office Visit - New Patient, Low Complexity | $218 | 89% | $24 |
| Office Visit - New Patient, Minor | $151 | 89% | $17 |
| Office Visit - New Patient, Moderate Complexity | $334 | 89% | $37 |
| Pap Test | $254 | 89% | $28 |
| Physical Therapy - High Complexity Evaluation | $547 | 89% | $60 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $174 | 89% | $19 |
| Ultrasound - Abdominal, Complete | $1,587 | 89% | $175 |
| Ultrasound - Abdominal, Limited | $1,030 | 89% | $113 |
| Ultrasound - Breast (outpatient) | $1,605 | 89% | $177 |
| Ultrasound - Head and Neck | $1,232 | 89% | $135 |
| Ultrasound - Pelvic (outpatient) | $1,383 | 89% | $152 |
| Ultrasound - Pregnancy Follow-Up | $1,433 | 89% | $158 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $5,096 | 89% | $561 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $6,375 | 89% | $701 |
| Urine Capacity Measurement | $901 | 89% | $99 |
| Urine Test - Automated with Microscope Examination | $135 | 89% | $15 |
| Urine Test - Automated without Microscope | $89 | 89% | $10 |
| Urine Test - Chlamydia | $130 | 89% | $14 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $130 | 89% | $14 |
| Urine Test - Pregnancy | $28 | 89% | $3 |
| Urine Test - Urinalysis, Manual Test | $12 | 89% | $1 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $130 | 89% | $14 |
| X-Ray - Abdomen | $1,186 | 89% | $130 |
| X-Ray - Ankle (outpatient) | $746 | 89% | $82 |
| X-Ray - Chest (outpatient) | $793 | 89% | $87 |
| X-Ray - Foot (outpatient) | $877 | 89% | $96 |
| X-Ray - Hand | $1,118 | 89% | $123 |
| X-Ray - Hip | $359 | 89% | $40 |
| X-Ray - Knee (outpatient) | $855 | 89% | $94 |
| X-Ray - Neck, Cervical Spine | $642 | 89% | $71 |
| X-Ray - Shoulder (outpatient) | $689 | 89% | $76 |
| X-Ray - Spine (outpatient) | $898 | 89% | $99 |
| X-Ray - Wrist (outpatient) | $1,109 | 89% | $122 |
