| Arthrocentesis (outpatient) | $494 | 57% | $212 |
| Arthroscopic Knee Surgery (outpatient) | $15,215 | 57% | $6,543 |
| Arthroscopic Shoulder Surgery | $40,928 | 57% | $17,599 |
| Bacterial Culture - Aerobic Isolates | $83 | 57% | $36 |
| Bacterial Culture - Swab | $74 | 57% | $32 |
| Biopsy - Breast | $8,182 | 57% | $3,518 |
| Biopsy - Endometrial (Uterus) | $1,437 | 57% | $618 |
| Biopsy - Punch Biopsy of Skin | $1,052 | 57% | $452 |
| Biopsy - Tangential Biopsy of Skin | $902 | 57% | $388 |
| Blood Test - Basic Metabolic Panel | $74 | 57% | $32 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $120 | 57% | $51 |
| Blood Test - Cholesterol Test, Lipid Panel | $143 | 57% | $62 |
| Blood Test - Clotting Time | $67 | 57% | $29 |
| Blood Test - Coagulation Assessment | $113 | 57% | $49 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $62 | 57% | $27 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $102 | 57% | $44 |
| Blood Test - Comprehensive Metabolic Panel | $91 | 57% | $39 |
| Blood Test - Electrolytes Panel | $81 | 57% | $35 |
| Blood Test - Ferritin (Blood Protein) Level | $135 | 57% | $58 |
| Blood Test - Folic Acid Level | $131 | 57% | $56 |
| Blood Test - General Health Panel | $378 | 57% | $163 |
| Blood Test - Hepatic (Liver) Function Panel | $105 | 57% | $45 |
| Blood Test - Hepatitis C Antibody Level | $142 | 57% | $61 |
| Blood Test - Iron Level | $87 | 57% | $37 |
| Blood Test - LDL Cholesterol Level | $78 | 57% | $34 |
| Blood Test - Lipase (fat enzyme) Level | $153 | 57% | $66 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $152 | 57% | $65 |
| Blood Test - Renal (Kidney) Function Panel | $71 | 57% | $31 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $185 | 57% | $80 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $126 | 57% | $54 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $184 | 57% | $79 |
| Blood Test - Vitamin D-3 Level | $247 | 57% | $106 |
| Bone Density Scan (outpatient) | $571 | 57% | $245 |
| Colonoscopy - Diagnostic (outpatient) | $6,165 | 57% | $2,651 |
| Colonoscopy - With Biopsy (outpatient) | $6,873 | 57% | $2,955 |
| Colonoscopy - With Polyp Removal (outpatient) | $7,448 | 57% | $3,203 |
| CT Scan - Abdomen and Pelvis, with Contrast | $4,323 | 57% | $1,859 |
| CT Scan - Chest, with Contrast (outpatient) | $2,542 | 57% | $1,093 |
| CT Scan - Head/Brain, without Contrast | $2,345 | 57% | $1,008 |
| Cystoscopy | $1,053 | 57% | $453 |
| Destruction of Lesion (outpatient) | $455 | 57% | $195 |
| Destruction of Lesions, up to 14 | $523 | 57% | $225 |
| Detection test for Human Papillomavirus (HPV) | $384 | 57% | $165 |
| Electrocardiogram (ECG or EKG) | $775 | 57% | $333 |
| Emergency Department Visit - Low Complexity (outpatient) | $465 | 57% | $200 |
| Emergency Department Visit - Minor (outpatient) | $411 | 57% | $177 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $691 | 57% | $297 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $104 | 57% | $45 |
| Fetal Non-Stress Test | $969 | 57% | $417 |
| Gall Bladder Surgery (outpatient) | $19,612 | 57% | $8,433 |
| Hernia Repair - Laparoscopic (outpatient) | $25,614 | 57% | $11,014 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $110 | 57% | $47 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $184 | 57% | $79 |
| Lab Test - Detection test for Influenza Virus | $142 | 57% | $61 |
| Lab Test - Smear for Microorganism | $64 | 57% | $27 |
| Mammogram (outpatient) | $787 | 57% | $338 |
| MRI - Back (outpatient) | $2,800 | 57% | $1,204 |
| MRI - Brain (outpatient) | $4,975 | 57% | $2,139 |
| MRI - Knee (outpatient) | $2,949 | 57% | $1,268 |
| MRI - Pelvis (outpatient) | $5,629 | 57% | $2,421 |
| MRI - Shoulder, Elbow, or Wrist | $2,949 | 57% | $1,268 |
| Myocardial Imaging (outpatient) | $8,381 | 57% | $3,604 |
| Office Visit - Basic | $109 | 57% | $47 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $280 | 57% | $121 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $303 | 57% | $130 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $303 | 57% | $130 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $355 | 57% | $153 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $278 | 57% | $120 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $258 | 57% | $111 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $239 | 57% | $103 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $263 | 57% | $113 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $264 | 57% | $113 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $288 | 57% | $124 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $238 | 57% | $102 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $219 | 57% | $94 |
| Office Visit - Established Patient, High Complexity | $360 | 57% | $155 |
| Office Visit - Established Patient, Low Complexity | $187 | 57% | $80 |
| Office Visit - Established Patient, Moderate Complexity | $269 | 57% | $116 |
| Office Visit - New Patient, Low Complexity | $270 | 57% | $116 |
| Office Visit - New Patient, Minor | $186 | 57% | $80 |
| Office Visit - New Patient, Moderate Complexity | $415 | 57% | $178 |
| Pap Test | $163 | 57% | $70 |
| Physical Therapy - Application of Hot or Cold Pack | $32 | 57% | $14 |
| Physical Therapy - High Complexity Evaluation | $474 | 57% | $204 |
| Physical Therapy - Low Complexity Evaluation | $474 | 57% | $204 |
| Physical Therapy - Manual Therapy | $149 | 57% | $64 |
| Physical Therapy - Self-care or Home Management Training | $134 | 57% | $58 |
| Physical Therapy - Therapeutic Activities | $133 | 57% | $57 |
| Physical Therapy - Therapeutic Exercises | $140 | 57% | $60 |
| Physical Therapy - Ultrasound Therapy | $122 | 57% | $52 |
| Psychiatric Diagnostic Evaluation | $277 | 57% | $119 |
| Psychotherapy - 30 Minutes | $167 | 57% | $72 |
| Psychotherapy - 45 Minutes | $148 | 57% | $64 |
| Psychotherapy - 60 Minutes | $217 | 57% | $93 |
| Psychotherapy - Family Session | $205 | 57% | $88 |
| Strep Test (Streptococcus, group A) | $28 | 57% | $12 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $74 | 57% | $32 |
| Ultrasound - Abdominal, Complete | $1,209 | 57% | $520 |
| Ultrasound - Abdominal, Limited | $885 | 57% | $381 |
| Ultrasound - Breast (outpatient) | $1,025 | 57% | $441 |
| Ultrasound - Head and Neck | $700 | 57% | $301 |
| Ultrasound - Pelvic (outpatient) | $722 | 57% | $310 |
| Ultrasound - Pregnancy (outpatient) | $405 | 57% | $174 |
| Ultrasound - Pregnancy Follow-Up | $457 | 57% | $197 |
| Ultrasound - Transvaginal (non-maternity) | $604 | 57% | $260 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $5,050 | 57% | $2,171 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $6,014 | 57% | $2,586 |
| Urine Capacity Measurement | $337 | 57% | $145 |
| Urine Test - Automated with Microscope Examination | $63 | 57% | $27 |
| Urine Test - Automated without Microscope | $32 | 57% | $14 |
| Urine Test - Bacterial Culture | $32 | 57% | $14 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $61 | 57% | $26 |
| Urine Test - Chlamydia | $192 | 57% | $82 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $192 | 57% | $82 |
| Urine Test - Microalbumin (Protein) Level | $96 | 57% | $41 |
| Urine Test - Pregnancy | $16 | 57% | $7 |
| Urine Test - Urinalysis, Manual Test | $5 | 57% | $2 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $296 | 57% | $127 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $83 | 57% | $36 |
| X-Ray - Abdomen | $661 | 57% | $284 |
| X-Ray - Ankle (outpatient) | $576 | 57% | $248 |
| X-Ray - Chest (outpatient) | $625 | 57% | $269 |
| X-Ray - Foot (outpatient) | $551 | 57% | $237 |
| X-Ray - Hand | $578 | 57% | $249 |
| X-Ray - Hip | $616 | 57% | $265 |
| X-Ray - Knee (outpatient) | $586 | 57% | $252 |
| X-Ray - Middle Back, Thoracic Spine | $768 | 57% | $330 |
| X-Ray - Neck, Cervical Spine | $602 | 57% | $259 |
| X-Ray - Pelvis | $533 | 57% | $229 |
| X-Ray - Shoulder (outpatient) | $579 | 57% | $249 |
| X-Ray - Spine (outpatient) | $710 | 57% | $305 |
| X-Ray - Wrist (outpatient) | $526 | 57% | $226 |
