| Arthrocentesis (outpatient) | $655 | 40% | $393 | 
Medium |
| Arthroscopic Knee Surgery (outpatient) | $15,601 | 40% | $9,360 |
Medium |
| Arthroscopic Shoulder Surgery | $46,195 | 40% | $27,717 | 
High |
| Bacterial Culture Swab | $71 | 40% | $43 |
Medium |
| Blood Test - Basic Metabolic Panel | $43 | 40% | $26 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $87 | 40% | $52 |
Medium |
| Blood Test - Cholesterol Test, Lipid Panel | $90 | 40% | $54 |
Medium |
| Blood Test - Clotting Time | $28 | 40% | $17 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $40 | 40% | $24 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $103 | 40% | $62 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $51 | 40% | $31 |
Medium |
| Blood Test - Electrolytes Panel | $65 | 40% | $39 |
Medium |
| Blood Test - Folic Acid Level | $138 | 40% | $83 |
Medium |
| Blood Test - General Health Panel | $188 | 40% | $113 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $58 | 40% | $35 |
Medium |
| Blood Test - Hepatitis C Antibody Level | $110 | 40% | $66 |
Medium |
| Blood Test - LDL Cholesterol Level | $58 | 40% | $35 |
Medium |
| Blood Test - Lipase (fat enzyme) Level | $143 | 40% | $86 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $100 | 40% | $60 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $35 | 40% | $21 |
Medium |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $92 | 40% | $55 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $66 | 40% | $40 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $87 | 40% | $52 |
Medium |
| Blood Test - Vitamin D-3 Level | $200 | 40% | $120 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $6,036 | 40% | $3,621 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $7,623 | 40% | $4,574 |
High |
| Colonoscopy - With Polyp Removal (outpatient) | $7,701 | 40% | $4,620 |
High |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,934 | 40% | $4,161 |
High |
| CT Scan - Chest, with Contrast (outpatient) | $4,160 | 40% | $2,496 |
Medium |
| CT Scan - Head/Brain, without Contrast | $3,532 | 40% | $2,119 |
Medium |
| Cystoscopy | $1,815 | 40% | $1,089 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $457 | 40% | $274 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $235 | 40% | $141 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $680 | 40% | $408 |
Medium |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $58 | 40% | $35 |
Medium |
| Fetal Non-Stress Test | $873 | 40% | $524 |
Medium |
| Gall Bladder Surgery (outpatient) | $32,588 | 40% | $19,553 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $29,912 | 40% | $17,947 |
Medium |
| Laryngoscopy - Diagnostic | $773 | 40% | $464 |
Medium |
| Mammogram (outpatient) | $940 | 40% | $564 |
Medium |
| MRI - Back (outpatient) | $1,508 | 40% | $905 |
Medium |
| MRI - Brain (outpatient) | $7,778 | 40% | $4,667 |
Medium |
| MRI - Knee (outpatient) | $1,549 | 40% | $929 |
Medium |
| MRI - Pelvis (outpatient) | $7,016 | 40% | $4,210 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $2,971 | 40% | $1,783 |
High |
| Myocardial Imaging (outpatient) | $10,193 | 40% | $6,116 |
Medium |
| Nasal Endoscopy - Diagnostic | $907 | 40% | $544 |
Medium |
| Office Visit - Basic | $175 | 40% | $105 |
Medium |
| Physical Therapy - Application of Blood Vessel Compression or Decompression Device | $155 | 40% | $93 |
Medium |
| Physical Therapy - High Complexity Evaluation | $425 | 40% | $255 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $425 | 40% | $255 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $425 | 40% | $255 |
Medium |
| Physical Therapy - Self-care or Home Management Training | $125 | 40% | $75 |
Medium |
| Physical Therapy - Therapeutic Exercises | $146 | 40% | $88 |
Medium |
| Strep Test (Streptococcus, group A) | $100 | 40% | $60 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $53 | 40% | $32 |
Medium |
| Tonsillectomy with Adenoidectomy (outpatient) | $13,451 | 40% | $8,071 |
Medium |
| Ultrasound - Abdominal, Complete | $1,929 | 40% | $1,157 |
Medium |
| Ultrasound - Abdominal, Limited | $1,284 | 40% | $770 |
Medium |
| Ultrasound - Head and Neck | $1,109 | 40% | $665 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $838 | 40% | $503 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $1,202 | 40% | $721 |
High |
| Ultrasound - Transvaginal (non-maternity) | $1,003 | 40% | $602 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $8,728 | 40% | $5,237 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $7,196 | 40% | $4,317 |
Medium |
| Urine Capacity Measurement | $717 | 40% | $430 |
High |
| Urine Test - Automated with Microscope Examination | $50 | 40% | $30 |
Medium |
| Urine Test - Automated without Microscope | $19 | 40% | $11 |
Medium |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $50 | 40% | $30 |
Medium |
| Urine Test - Chlamydia | $137 | 40% | $82 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $137 | 40% | $82 |
Medium |
| Urine Test - Pregnancy | $55 | 40% | $33 |
Medium |
| X-Ray - Abdomen | $762 | 40% | $457 |
Medium |
| X-Ray - Ankle (outpatient) | $704 | 40% | $422 |
Medium |
| X-Ray - Chest (outpatient) | $884 | 40% | $530 |
Medium |
| X-Ray - Foot (outpatient) | $861 | 40% | $517 |
Medium |
| X-Ray - Hand | $991 | 40% | $594 |
Medium |
| X-Ray - Hip | $779 | 40% | $467 |
Medium |
| X-Ray - Knee (outpatient) | $572 | 40% | $343 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $875 | 40% | $525 |
Medium |
| X-Ray - Neck, Cervical Spine | $618 | 40% | $371 |
Medium |
| X-Ray - Pelvis | $489 | 40% | $294 |
High |
| X-Ray - Shoulder (outpatient) | $881 | 40% | $529 |
Medium |
| X-Ray - Spine (outpatient) | $939 | 40% | $563 |
Medium |
| X-Ray - Wrist (outpatient) | $852 | 40% | $511 |
Medium |
