| Bacterial Culture - Aerobic Isolates | $62 | 89% | $7 |
| Bacterial Culture - Swab | $116 | 89% | $13 |
| Biopsy - Breast | $8,439 | 89% | $928 |
| Blood Test - Basic Metabolic Panel | $115 | 89% | $13 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $121 | 89% | $13 |
| Blood Test - Cholesterol Test, Lipid Panel | $178 | 89% | $20 |
| Blood Test - Clotting Time | $54 | 89% | $6 |
| Blood Test - Coagulation Assessment | $174 | 89% | $19 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $89 | 89% | $10 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $107 | 89% | $12 |
| Blood Test - Comprehensive Metabolic Panel | $141 | 89% | $16 |
| Blood Test - Ferritin (Blood Protein) Level | $180 | 89% | $20 |
| Blood Test - Folic Acid Level | $196 | 89% | $22 |
| Blood Test - Hepatic (Liver) Function Panel | $103 | 89% | $11 |
| Blood Test - Hepatitis C Antibody Level | $204 | 89% | $22 |
| Blood Test - Iron Level | $89 | 89% | $10 |
| Blood Test - Lipase (fat enzyme) Level | $87 | 89% | $10 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $181 | 89% | $20 |
| Blood Test - Renal (Kidney) Function Panel | $116 | 89% | $13 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $208 | 89% | $23 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $123 | 89% | $14 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $221 | 89% | $24 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $159 | 89% | $18 |
| Blood Test - Vitamin D-3 Level | $284 | 89% | $31 |
| Bone Density Scan (outpatient) | $930 | 89% | $102 |
| Colonoscopy - Diagnostic (outpatient) | $5,912 | 89% | $650 |
| Colonoscopy - With Biopsy (outpatient) | $8,836 | 89% | $972 |
| Colonoscopy - With Polyp Removal (outpatient) | $9,194 | 89% | $1,011 |
| CT Scan - Chest, with Contrast (outpatient) | $6,989 | 89% | $769 |
| CT Scan - Head/Brain, without Contrast | $3,963 | 89% | $436 |
| Emergency Department Visit - Low Complexity (outpatient) | $1,336 | 89% | $147 |
| Emergency Department Visit - Minor (outpatient) | $837 | 89% | $92 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $2,112 | 89% | $232 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $116 | 89% | $13 |
| Fetal Non-Stress Test | $3,135 | 89% | $345 |
| Gall Bladder Surgery (outpatient) | $44,219 | 89% | $4,864 |
| Hernia Repair - Laparoscopic (outpatient) | $45,818 | 89% | $5,040 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $140 | 89% | $15 |
| Lab Test - Smear for Microorganism | $59 | 89% | $7 |
| Mammogram (outpatient) | $824 | 89% | $91 |
| MRI - Back (outpatient) | $4,837 | 89% | $532 |
| MRI - Brain (outpatient) | $6,655 | 89% | $732 |
| MRI - Knee (outpatient) | $4,382 | 89% | $482 |
| MRI - Pelvis (outpatient) | $6,998 | 89% | $770 |
| MRI - Shoulder, Elbow, or Wrist | $4,714 | 89% | $518 |
| Myocardial Imaging (outpatient) | $8,239 | 89% | $906 |
| Office Visit - Basic | $95 | 89% | $10 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $315 | 89% | $35 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $336 | 89% | $37 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $273 | 89% | $30 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $294 | 89% | $32 |
| Office Visit - Established Patient, High Complexity | $331 | 89% | $36 |
| Office Visit - Established Patient, Low Complexity | $163 | 89% | $18 |
| Office Visit - Established Patient, Moderate Complexity | $226 | 89% | $25 |
| Physical Therapy - Application of Mechanical Traction | $65 | 89% | $7 |
| Physical Therapy - High Complexity Evaluation | $472 | 89% | $52 |
| Physical Therapy - Low Complexity Evaluation | $472 | 89% | $52 |
| Physical Therapy - Manual Therapy | $159 | 89% | $17 |
| Physical Therapy - Moderate Complexity Evaluation | $472 | 89% | $52 |
| Physical Therapy - Self-care or Home Management Training | $159 | 89% | $17 |
| Physical Therapy - Therapeutic Activities | $96 | 89% | $11 |
| Physical Therapy - Therapeutic Exercises | $159 | 89% | $17 |
| Physical Therapy - Ultrasound Therapy | $65 | 89% | $7 |
| Strep Test (Streptococcus, group A) | $71 | 89% | $8 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $86 | 89% | $9 |
| Ultrasound - Abdominal, Complete | $1,681 | 89% | $185 |
| Ultrasound - Abdominal, Limited | $607 | 89% | $67 |
| Ultrasound - Breast (outpatient) | $1,745 | 89% | $192 |
| Ultrasound - Head and Neck | $1,306 | 89% | $144 |
| Ultrasound - Pregnancy (outpatient) | $507 | 89% | $56 |
| Ultrasound - Pregnancy Follow-Up | $490 | 89% | $54 |
| Ultrasound - Transvaginal (non-maternity) | $1,385 | 89% | $152 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $7,364 | 89% | $810 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $10,372 | 89% | $1,141 |
| Urine Test - Automated with Microscope Examination | $152 | 89% | $17 |
| Urine Test - Automated without Microscope | $122 | 89% | $13 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $89 | 89% | $10 |
| Urine Test - Chlamydia | $146 | 89% | $16 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $146 | 89% | $16 |
| Urine Test - Pregnancy | $152 | 89% | $17 |
| Urine Test - Urinalysis, Manual Test | $34 | 89% | $4 |
| X-Ray - Abdomen | $503 | 89% | $55 |
| X-Ray - Ankle (outpatient) | $810 | 89% | $89 |
| X-Ray - Chest (outpatient) | $402 | 89% | $44 |
| X-Ray - Foot (outpatient) | $871 | 89% | $96 |
| X-Ray - Hand | $811 | 89% | $89 |
| X-Ray - Hip | $743 | 89% | $82 |
| X-Ray - Knee (outpatient) | $536 | 89% | $59 |
| X-Ray - Neck, Cervical Spine | $783 | 89% | $86 |
| X-Ray - Shoulder (outpatient) | $749 | 89% | $82 |
| X-Ray - Spine (outpatient) | $802 | 89% | $88 |
| X-Ray - Wrist (outpatient) | $863 | 89% | $95 |
