| Arthrocentesis (outpatient) | $654 | 40% | $392 |
| Arthroscopic Knee Surgery (outpatient) | $15,626 | 40% | $9,376 |
| Arthroscopic Shoulder Surgery | $53,203 | 40% | $31,922 |
| Bacterial Culture - Aerobic Isolates | $82 | 40% | $49 |
| Bacterial Culture - Swab | $71 | 40% | $43 |
| Biopsy - Breast | $2,654 | 40% | $1,593 |
| Biopsy - Endometrial (Uterus) | $1,193 | 40% | $716 |
| Blood Test - Basic Metabolic Panel | $41 | 40% | $25 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $87 | 40% | $52 |
| Blood Test - Cholesterol Test, Lipid Panel | $90 | 40% | $54 |
| Blood Test - Clotting Time | $54 | 40% | $32 |
| Blood Test - Coagulation Assessment | $83 | 40% | $50 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $40 | 40% | $24 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $103 | 40% | $62 |
| Blood Test - Comprehensive Metabolic Panel | $49 | 40% | $30 |
| Blood Test - Electrolytes Panel | $63 | 40% | $38 |
| Blood Test - Ferritin (Blood Protein) Level | $84 | 40% | $50 |
| Blood Test - Folic Acid Level | $138 | 40% | $83 |
| Blood Test - General Health Panel | $188 | 40% | $113 |
| Blood Test - Hepatic (Liver) Function Panel | $106 | 40% | $64 |
| Blood Test - Hepatitis C Antibody Level | $106 | 40% | $64 |
| Blood Test - Iron Level | $38 | 40% | $23 |
| Blood Test - LDL Cholesterol Level | $58 | 40% | $35 |
| Blood Test - Lipase (fat enzyme) Level | $143 | 40% | $86 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $100 | 40% | $60 |
| Blood Test - Renal (Kidney) Function Panel | $34 | 40% | $20 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $92 | 40% | $55 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $66 | 40% | $40 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $143 | 40% | $86 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $84 | 40% | $50 |
| Blood Test - Vitamin D-3 Level | $200 | 40% | $120 |
| Bone Density Scan (outpatient) | $708 | 40% | $425 |
| Colonoscopy - Diagnostic (outpatient) | $5,803 | 40% | $3,482 |
| Colonoscopy - With Biopsy (outpatient) | $8,068 | 40% | $4,841 |
| Colonoscopy - With Polyp Removal (outpatient) | $8,439 | 40% | $5,064 |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,934 | 40% | $4,161 |
| CT Scan - Chest, with Contrast (outpatient) | $4,160 | 40% | $2,496 |
| CT Scan - Head/Brain, without Contrast | $3,532 | 40% | $2,119 |
| Detection test for Human Papillomavirus (HPV) | $249 | 40% | $149 |
| Emergency Department Visit - Low Complexity (outpatient) | $457 | 40% | $274 |
| Emergency Department Visit - Minor (outpatient) | $235 | 40% | $141 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $758 | 40% | $455 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $56 | 40% | $33 |
| Fetal Non-Stress Test | $879 | 40% | $527 |
| Gall Bladder Surgery (outpatient) | $30,171 | 40% | $18,103 |
| Hernia Repair - Laparoscopic (outpatient) | $29,734 | 40% | $17,841 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $83 | 40% | $50 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $97 | 40% | $58 |
| Lab Test - Smear for Microorganism | $39 | 40% | $23 |
| Laryngoscopy - Diagnostic | $722 | 40% | $433 |
| Mammogram (outpatient) | $1,021 | 40% | $612 |
| MRI - Back (outpatient) | $1,508 | 40% | $905 |
| MRI - Brain (outpatient) | $7,724 | 40% | $4,634 |
| MRI - Knee (outpatient) | $1,549 | 40% | $929 |
| MRI - Pelvis (outpatient) | $7,016 | 40% | $4,210 |
| MRI - Shoulder, Elbow, or Wrist | $1,588 | 40% | $953 |
| Myocardial Imaging (outpatient) | $10,641 | 40% | $6,385 |
| Nasal Endoscopy - Diagnostic | $951 | 40% | $571 |
| Office Visit - Basic | $175 | 40% | $105 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $389 | 40% | $233 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $449 | 40% | $270 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $286 | 40% | $171 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $296 | 40% | $178 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $305 | 40% | $183 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $326 | 40% | $195 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $290 | 40% | $174 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $254 | 40% | $152 |
| Office Visit - Established Patient, High Complexity | $407 | 40% | $244 |
| Office Visit - Established Patient, Low Complexity | $210 | 40% | $126 |
| Office Visit - Established Patient, Moderate Complexity | $305 | 40% | $183 |
| Office Visit - New Patient, Low Complexity | $303 | 40% | $182 |
| Office Visit - New Patient, Minor | $213 | 40% | $128 |
| Office Visit - New Patient, Moderate Complexity | $473 | 40% | $284 |
| Physical Therapy - Application of Blood Vessel Compression or Decompression Device | $155 | 40% | $93 |
| Physical Therapy - Electrical Stimulation Therapy | $72 | 40% | $43 |
| Physical Therapy - High Complexity Evaluation | $425 | 40% | $255 |
| Physical Therapy - Low Complexity Evaluation | $425 | 40% | $255 |
| Physical Therapy - Manual Electrical Stimulation Therapy, 15 minutes | $54 | 40% | $32 |
| Physical Therapy - Manual Therapy | $143 | 40% | $86 |
| Physical Therapy - Moderate Complexity Evaluation | $425 | 40% | $255 |
| Physical Therapy - Self-care or Home Management Training | $125 | 40% | $75 |
| Physical Therapy - Therapeutic Exercises | $146 | 40% | $88 |
| Physical Therapy - Ultrasound Therapy | $70 | 40% | $42 |
| Strep Test (Streptococcus, group A) | $96 | 40% | $57 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $53 | 40% | $32 |
| Tonsillectomy with Adenoidectomy (outpatient) | $14,200 | 40% | $8,520 |
| Ultrasound - Abdominal, Complete | $1,929 | 40% | $1,157 |
| Ultrasound - Abdominal, Limited | $1,284 | 40% | $770 |
| Ultrasound - Head and Neck | $1,109 | 40% | $665 |
| Ultrasound - Pelvic (outpatient) | $1,441 | 40% | $864 |
| Ultrasound - Pregnancy (outpatient) | $1,061 | 40% | $637 |
| Ultrasound - Pregnancy Follow-Up | $923 | 40% | $554 |
| Ultrasound - Transvaginal (non-maternity) | $983 | 40% | $590 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $8,009 | 40% | $4,806 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $7,489 | 40% | $4,493 |
| Urine Capacity Measurement | $608 | 40% | $365 |
| Urine Test - Automated with Microscope Examination | $48 | 40% | $29 |
| Urine Test - Automated without Microscope | $19 | 40% | $11 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $48 | 40% | $29 |
| Urine Test - Chlamydia | $131 | 40% | $79 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $131 | 40% | $79 |
| Urine Test - Microalbumin (Protein) Level | $27 | 40% | $16 |
| Urine Test - Pregnancy | $55 | 40% | $33 |
| Urine Test - Urinalysis, Manual Test | $24 | 40% | $14 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $433 | 40% | $260 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $91 | 40% | $55 |
| X-Ray - Abdomen | $715 | 40% | $429 |
| X-Ray - Ankle (outpatient) | $731 | 40% | $438 |
| X-Ray - Chest (outpatient) | $933 | 40% | $560 |
| X-Ray - Foot (outpatient) | $975 | 40% | $585 |
| X-Ray - Hand | $1,116 | 40% | $670 |
| X-Ray - Hip | $806 | 40% | $484 |
| X-Ray - Knee (outpatient) | $471 | 40% | $283 |
| X-Ray - Middle Back, Thoracic Spine | $683 | 40% | $410 |
| X-Ray - Neck, Cervical Spine | $607 | 40% | $364 |
| X-Ray - Pelvis | $1,058 | 40% | $635 |
| X-Ray - Shoulder (outpatient) | $789 | 40% | $473 |
| X-Ray - Spine (outpatient) | $1,072 | 40% | $643 |
| X-Ray - Wrist (outpatient) | $1,032 | 40% | $619 |
