| Arthrocentesis (outpatient) | $1,493 | 0% | $1,493 | 
Medium |
| Blood Test - Electrolytes Panel | $166 | 0% | $166 |
Medium |
| Blood Test - Hepatitis C Antibody Level | $180 | 0% | $180 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $145 | 0% | $145 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $184 | 0% | $184 |
Medium |
| Blood Test - Vitamin D-3 Level | $259 | 0% | $259 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $5,546 | 0% | $5,546 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $7,633 | 0% | $7,633 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $8,651 | 0% | $8,651 |
Medium |
| CT Scan - Head/Brain, without Contrast | $967 | 0% | $967 |
Medium |
| Detection Test for Human Papillomavirus (HPV) | $218 | 0% | $218 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $282 | 0% | $282 |
Medium |
| MRI - Back (outpatient) | $1,888 | 0% | $1,888 | 
High |
| MRI - Brain (outpatient) | $3,345 | 0% | $3,345 |
Medium |
| MRI - Knee (outpatient) | $1,856 | 0% | $1,856 |
High |
| MRI - Shoulder, Elbow, or Wrist | $1,845 | 0% | $1,845 |
Medium |
| Physical Therapy - Application of Mechanical Traction | $46 | 0% | $46 |
Medium |
| Physical Therapy - Manual Therapy | $86 | 0% | $86 |
Medium |
| Physical Therapy - Neuromuscular Reeducation | $96 | 0% | $96 |
Medium |
| Physical Therapy - Self-care or Home Management Training | $99 | 0% | $99 |
Medium |
| Physical Therapy - Therapeutic Exercises | $92 | 0% | $92 |
Medium |
| Physical Therapy - Ultrasound Therapy | $36 | 0% | $36 |
Medium |
| Psychiatric Diagnostic Evaluation | $261 | 0% | $261 |
Medium |
| Psychotherapy - 45 Minutes | $173 | 0% | $173 |
Medium |
| Psychotherapy - Group Session | $260 | 0% | $260 |
Medium |
| Ultrasound - Abdominal, Limited | $875 | 0% | $875 |
High |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,400 | 0% | $5,400 | 
Low |
| Urine Capacity Measurement | $838 | 0% | $838 |
High |
| Urine Test - Automated with Microscope Examination | $111 | 0% | $111 |
Medium |
| Urine Test - Automated without Microscope | $79 | 0% | $79 |
Medium |
| Urine Test - Chlamydia | $224 | 0% | $224 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $217 | 0% | $217 |
Medium |
| Urine Test - Pregnancy | $144 | 0% | $144 |
Medium |
| X-Ray - Chest (outpatient) | $683 | 0% | $683 |
Medium |
| X-Ray - Foot (outpatient) | $640 | 0% | $640 |
High |
| X-Ray - Hand | $760 | 0% | $760 |
High |
| X-Ray - Shoulder (outpatient) | $520 | 0% | $520 |
Medium |
| X-Ray - Spine (outpatient) | $799 | 0% | $799 |
Medium |
