| Arthrocentesis (outpatient) | $539 | 0% | $539 |
| MRI - Back (outpatient) | $1,508 | 0% | $1,508 |
| MRI - Knee (outpatient) | $1,549 | 0% | $1,549 |
| MRI - Shoulder, Elbow, or Wrist | $1,524 | 0% | $1,524 |
| Physical Therapy - Application of Blood Vessel Compression or Decompression Device | $53 | 0% | $53 |
| Physical Therapy - Low Complexity Evaluation | $326 | 0% | $326 |
| Physical Therapy - Manual Therapy | $74 | 0% | $74 |
| Physical Therapy - Moderate Complexity Evaluation | $210 | 0% | $210 |
| Physical Therapy - Neuromuscular Reeducation | $89 | 0% | $89 |
| Physical Therapy - Therapeutic Exercises | $91 | 0% | $91 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $53 | 0% | $53 |
| X-Ray - Ankle (outpatient) | $312 | 0% | $312 |
| X-Ray - Foot (outpatient) | $306 | 0% | $306 |
| X-Ray - Hand | $314 | 0% | $314 |
| X-Ray - Hip | $348 | 0% | $348 |
| X-Ray - Knee (outpatient) | $420 | 0% | $420 |
| X-Ray - Neck, Cervical Spine | $412 | 0% | $412 |
| X-Ray - Pelvis | $334 | 0% | $334 |
| X-Ray - Shoulder (outpatient) | $399 | 0% | $399 |
| X-Ray - Spine (outpatient) | $418 | 0% | $418 |
| X-Ray - Wrist (outpatient) | $488 | 0% | $488 |
