| Arthrocentesis (outpatient) | $1,931 | 0% | $1,931 |
| Bacterial Culture - Aerobic Isolates | $117 | 0% | $117 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $125 | 0% | $125 |
| Blood Test - Coagulation Assessment | $147 | 0% | $147 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $137 | 0% | $137 |
| Blood Test - Electrolytes Panel | $166 | 0% | $166 |
| Blood Test - Folic Acid Level | $189 | 0% | $189 |
| Blood Test - Hepatitis C Antibody Level | $180 | 0% | $180 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $203 | 0% | $203 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $151 | 0% | $151 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $191 | 0% | $191 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $187 | 0% | $187 |
| Blood Test - Vitamin D-3 Level | $266 | 0% | $266 |
| Colonoscopy - Diagnostic (outpatient) | $5,268 | 0% | $5,268 |
| Colonoscopy - With Biopsy (outpatient) | $7,913 | 0% | $7,913 |
| Colonoscopy - With Polyp Removal (outpatient) | $7,977 | 0% | $7,977 |
| CT Scan - Abdomen and Pelvis, with Contrast | $2,887 | 0% | $2,887 |
| CT Scan - Head/Brain, without Contrast | $1,505 | 0% | $1,505 |
| Cystoscopy | $3,059 | 0% | $3,059 |
| Detection test for Human Papillomavirus (HPV) | $221 | 0% | $221 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $282 | 0% | $282 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $209 | 0% | $209 |
| Lab Test - Smear for Microorganism | $99 | 0% | $99 |
| MRI - Back (outpatient) | $1,902 | 0% | $1,902 |
| MRI - Knee (outpatient) | $1,870 | 0% | $1,870 |
| MRI - Shoulder, Elbow, or Wrist | $1,857 | 0% | $1,857 |
| Physical Therapy - Application of Blood Vessel Compression or Decompression Device | $45 | 0% | $45 |
| Physical Therapy - Manual Electrical Stimulation Therapy, 15 minutes | $43 | 0% | $43 |
| Physical Therapy - Manual Therapy | $79 | 0% | $79 |
| Physical Therapy - Neuromuscular Reeducation | $98 | 0% | $98 |
| Physical Therapy - Self-care or Home Management Training | $97 | 0% | $97 |
| Physical Therapy - Therapeutic Exercises | $86 | 0% | $86 |
| Physical Therapy - Ultrasound Therapy | $37 | 0% | $37 |
| Psychotherapy - 30 Minutes | $117 | 0% | $117 |
| Psychotherapy - Group Session | $91 | 0% | $91 |
| Ultrasound - Abdominal, Limited | $891 | 0% | $891 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $6,184 | 0% | $6,184 |
| Urine Capacity Measurement | $881 | 0% | $881 |
| Urine Test - Automated with Microscope Examination | $111 | 0% | $111 |
| Urine Test - Automated without Microscope | $80 | 0% | $80 |
| Urine Test - Chlamydia | $227 | 0% | $227 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $221 | 0% | $221 |
| Urine Test - Microalbumin (Protein) Level | $103 | 0% | $103 |
| Urine Test - Pregnancy | $148 | 0% | $148 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $412 | 0% | $412 |
| X-Ray - Chest (outpatient) | $823 | 0% | $823 |
| X-Ray - Foot (outpatient) | $834 | 0% | $834 |
| X-Ray - Hand | $760 | 0% | $760 |
| X-Ray - Hip | $983 | 0% | $983 |
| X-Ray - Shoulder (outpatient) | $520 | 0% | $520 |
| X-Ray - Spine (outpatient) | $1,138 | 0% | $1,138 |
