| Arthrocentesis (outpatient) | $907 | 0% | $907 |
| Bacterial Culture - Aerobic Isolates | $59 | 0% | $59 |
| Bacterial Culture - Swab | $33 | 0% | $33 |
| Biopsy - Breast | $4,741 | 0% | $4,741 |
| Biopsy - Endometrial (Uterus) | $976 | 0% | $976 |
| Biopsy - Punch Biopsy of Skin | $1,162 | 0% | $1,162 |
| Blood Test - Basic Metabolic Panel | $45 | 0% | $45 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $29 | 0% | $29 |
| Blood Test - Cholesterol Test, Lipid Panel | $45 | 0% | $45 |
| Blood Test - Clotting Time | $18 | 0% | $18 |
| Blood Test - Coagulation Assessment | $26 | 0% | $26 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $39 | 0% | $39 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $47 | 0% | $47 |
| Blood Test - Comprehensive Metabolic Panel | $47 | 0% | $47 |
| Blood Test - Electrolytes Panel | $29 | 0% | $29 |
| Blood Test - Ferritin (Blood Protein) Level | $78 | 0% | $78 |
| Blood Test - Folic Acid Level | $50 | 0% | $50 |
| Blood Test - General Health Panel | $156 | 0% | $156 |
| Blood Test - Hepatic (Liver) Function Panel | $31 | 0% | $31 |
| Blood Test - Hepatitis C Antibody Level | $44 | 0% | $44 |
| Blood Test - Iron Level | $22 | 0% | $22 |
| Blood Test - LDL Cholesterol Level | $32 | 0% | $32 |
| Blood Test - Lipase (fat enzyme) Level | $24 | 0% | $24 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $105 | 0% | $105 |
| Blood Test - Renal (Kidney) Function Panel | $30 | 0% | $30 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $62 | 0% | $62 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $31 | 0% | $31 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $57 | 0% | $57 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $50 | 0% | $50 |
| Blood Test - Vitamin D-3 Level | $100 | 0% | $100 |
| Bone Density Scan (outpatient) | $429 | 0% | $429 |
| Colonoscopy - Diagnostic (outpatient) | $3,849 | 0% | $3,849 |
| Colonoscopy - With Biopsy (outpatient) | $4,579 | 0% | $4,579 |
| Colonoscopy - With Polyp Removal (outpatient) | $4,362 | 0% | $4,362 |
| CT Scan - Abdomen and Pelvis, with Contrast | $1,580 | 0% | $1,580 |
| CT Scan - Chest, with Contrast (outpatient) | $1,454 | 0% | $1,454 |
| CT Scan - Head/Brain, without Contrast | $506 | 0% | $506 |
| Detection test for Human Papillomavirus (HPV) | $87 | 0% | $87 |
| Emergency Department Visit - Low Complexity (outpatient) | $483 | 0% | $483 |
| Emergency Department Visit - Minor (outpatient) | $350 | 0% | $350 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $723 | 0% | $723 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $58 | 0% | $58 |
| Fetal Non-Stress Test | $741 | 0% | $741 |
| Gall Bladder Surgery (outpatient) | $16,953 | 0% | $16,953 |
| Hernia Repair - Laparoscopic (outpatient) | $14,714 | 0% | $14,714 |
| Kidney Stone Removal (outpatient) | $8,849 | 0% | $8,849 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $35 | 0% | $35 |
| Lab Test - Detection test for Influenza Virus | $39 | 0% | $39 |
| Lab Test - Smear for Microorganism | $33 | 0% | $33 |
| Mammogram (outpatient) | $601 | 0% | $601 |
| MRI - Back (outpatient) | $920 | 0% | $920 |
| MRI - Brain (outpatient) | $1,612 | 0% | $1,612 |
| MRI - Knee (outpatient) | $920 | 0% | $920 |
| MRI - Pelvis (outpatient) | $1,462 | 0% | $1,462 |
| MRI - Shoulder, Elbow, or Wrist | $1,008 | 0% | $1,008 |
| Myocardial Imaging (outpatient) | $5,901 | 0% | $5,901 |
| Nasal Endoscopy - Diagnostic | $1,362 | 0% | $1,362 |
| Office Visit - Basic | $147 | 0% | $147 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $369 | 0% | $369 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $383 | 0% | $383 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $446 | 0% | $446 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $354 | 0% | $354 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $303 | 0% | $303 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $357 | 0% | $357 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $332 | 0% | $332 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $361 | 0% | $361 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $301 | 0% | $301 |
| Office Visit - Established Patient, High Complexity | $470 | 0% | $470 |
| Office Visit - Established Patient, Low Complexity | $235 | 0% | $235 |
| Office Visit - Established Patient, Moderate Complexity | $351 | 0% | $351 |
| Office Visit - New Patient, Low Complexity | $350 | 0% | $350 |
| Office Visit - New Patient, Moderate Complexity | $534 | 0% | $534 |
| Pap Test | $100 | 0% | $100 |
| Physical Therapy - High Complexity Evaluation | $288 | 0% | $288 |
| Physical Therapy - Low Complexity Evaluation | $234 | 0% | $234 |
| Physical Therapy - Manual Therapy | $96 | 0% | $96 |
| Physical Therapy - Self-care or Home Management Training | $102 | 0% | $102 |
| Physical Therapy - Therapeutic Activities | $89 | 0% | $89 |
| Physical Therapy - Therapeutic Exercises | $104 | 0% | $104 |
| Physical Therapy - Ultrasound Therapy | $76 | 0% | $76 |
| Strep Test (Streptococcus, group A) | $42 | 0% | $42 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $36 | 0% | $36 |
| Ultrasound - Abdominal, Complete | $728 | 0% | $728 |
| Ultrasound - Abdominal, Limited | $506 | 0% | $506 |
| Ultrasound - Breast (outpatient) | $918 | 0% | $918 |
| Ultrasound - Head and Neck | $610 | 0% | $610 |
| Ultrasound - Pelvic (outpatient) | $578 | 0% | $578 |
| Ultrasound - Pregnancy (outpatient) | $838 | 0% | $838 |
| Ultrasound - Pregnancy Follow-Up | $656 | 0% | $656 |
| Ultrasound - Transvaginal (non-maternity) | $572 | 0% | $572 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $5,326 | 0% | $5,326 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,161 | 0% | $5,161 |
| Urine Test - Automated with Microscope Examination | $18 | 0% | $18 |
| Urine Test - Automated without Microscope | $25 | 0% | $25 |
| Urine Test - Bacterial Culture | $31 | 0% | $31 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $36 | 0% | $36 |
| Urine Test - Chlamydia | $87 | 0% | $87 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $87 | 0% | $87 |
| Urine Test - Microalbumin (Protein) Level | $21 | 0% | $21 |
| Urine Test - Pregnancy | $24 | 0% | $24 |
| Urine Test - Urinalysis, Manual Test | $11 | 0% | $11 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $347 | 0% | $347 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $105 | 0% | $105 |
| X-Ray - Abdomen | $324 | 0% | $324 |
| X-Ray - Ankle (outpatient) | $578 | 0% | $578 |
| X-Ray - Chest (outpatient) | $479 | 0% | $479 |
| X-Ray - Foot (outpatient) | $505 | 0% | $505 |
| X-Ray - Hand | $563 | 0% | $563 |
| X-Ray - Hip | $635 | 0% | $635 |
| X-Ray - Knee (outpatient) | $442 | 0% | $442 |
| X-Ray - Neck, Cervical Spine | $619 | 0% | $619 |
| X-Ray - Shoulder (outpatient) | $527 | 0% | $527 |
| X-Ray - Spine (outpatient) | $441 | 0% | $441 |
