| Arthrocentesis (outpatient) | $717 | 0% | $717 |
| Bacterial Culture - Aerobic Isolates | $55 | 0% | $55 |
| Bacterial Culture - Swab | $74 | 0% | $74 |
| Biopsy - Breast | $4,960 | 0% | $4,960 |
| Biopsy - Endometrial (Uterus) | $1,149 | 0% | $1,149 |
| Biopsy - Punch Biopsy of Skin | $828 | 0% | $828 |
| Blood Test - Basic Metabolic Panel | $78 | 0% | $78 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $44 | 0% | $44 |
| Blood Test - Cholesterol Test, Lipid Panel | $116 | 0% | $116 |
| Blood Test - Clotting Time | $26 | 0% | $26 |
| Blood Test - Coagulation Assessment | $42 | 0% | $42 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $70 | 0% | $70 |
| Blood Test - Comprehensive Metabolic Panel | $105 | 0% | $105 |
| Blood Test - Ferritin (Blood Protein) Level | $95 | 0% | $95 |
| Blood Test - Folic Acid Level | $67 | 0% | $67 |
| Blood Test - General Health Panel | $252 | 0% | $252 |
| Blood Test - Hepatic (Liver) Function Panel | $105 | 0% | $105 |
| Blood Test - Hepatitis C Antibody Level | $101 | 0% | $101 |
| Blood Test - Iron Level | $88 | 0% | $88 |
| Blood Test - LDL Cholesterol Level | $74 | 0% | $74 |
| Blood Test - Lipase (fat enzyme) Level | $67 | 0% | $67 |
| Blood Test - Pregnancy (Obstetric) Panel | $461 | 0% | $461 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $91 | 0% | $91 |
| Blood Test - Renal (Kidney) Function Panel | $68 | 0% | $68 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $77 | 0% | $77 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $76 | 0% | $76 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $91 | 0% | $91 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $77 | 0% | $77 |
| Blood Test - Vitamin D-3 Level | $150 | 0% | $150 |
| Bone Density Scan (outpatient) | $491 | 0% | $491 |
| Colonoscopy - Diagnostic (outpatient) | $4,265 | 0% | $4,265 |
| Colonoscopy - With Biopsy (outpatient) | $5,036 | 0% | $5,036 |
| Colonoscopy - With Polyp Removal (outpatient) | $5,252 | 0% | $5,252 |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,134 | 0% | $3,134 |
| CT Scan - Chest, with Contrast (outpatient) | $1,924 | 0% | $1,924 |
| CT Scan - Head/Brain, without Contrast | $1,251 | 0% | $1,251 |
| Destruction of Lesion (outpatient) | $464 | 0% | $464 |
| Detection test for Human Papillomavirus (HPV) | $134 | 0% | $134 |
| Electrocardiogram (ECG or EKG) | $661 | 0% | $661 |
| Emergency Department Visit - Low Complexity (outpatient) | $216 | 0% | $216 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $428 | 0% | $428 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $70 | 0% | $70 |
| Fetal Non-Stress Test | $933 | 0% | $933 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $69 | 0% | $69 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $33 | 0% | $33 |
| Lab Test - Detection test for Influenza Virus | $123 | 0% | $123 |
| Lab Test - Smear for Microorganism | $33 | 0% | $33 |
| Mammogram (outpatient) | $857 | 0% | $857 |
| MRI - Back (outpatient) | $2,679 | 0% | $2,679 |
| MRI - Brain (outpatient) | $5,316 | 0% | $5,316 |
| MRI - Knee (outpatient) | $1,944 | 0% | $1,944 |
| MRI - Shoulder, Elbow, or Wrist | $1,759 | 0% | $1,759 |
| Myocardial Imaging (outpatient) | $5,769 | 0% | $5,769 |
| Office Visit - Basic | $195 | 0% | $195 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $224 | 0% | $224 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $239 | 0% | $239 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $239 | 0% | $239 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $279 | 0% | $279 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $224 | 0% | $224 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $201 | 0% | $201 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $190 | 0% | $190 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $212 | 0% | $212 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $212 | 0% | $212 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $268 | 0% | $268 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $190 | 0% | $190 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $173 | 0% | $173 |
| Office Visit - Established Patient, High Complexity | $347 | 0% | $347 |
| Office Visit - Established Patient, Low Complexity | $223 | 0% | $223 |
| Office Visit - Established Patient, Moderate Complexity | $255 | 0% | $255 |
| Office Visit - New Patient, Low Complexity | $244 | 0% | $244 |
| Office Visit - New Patient, Minor | $238 | 0% | $238 |
| Office Visit - New Patient, Moderate Complexity | $314 | 0% | $314 |
| Pap Test | $132 | 0% | $132 |
| Physical Therapy - High Complexity Evaluation | $258 | 0% | $258 |
| Physical Therapy - Low Complexity Evaluation | $263 | 0% | $263 |
| Physical Therapy - Manual Electrical Stimulation Therapy, 15 minutes | $75 | 0% | $75 |
| Physical Therapy - Manual Therapy | $75 | 0% | $75 |
| Physical Therapy - Moderate Complexity Evaluation | $263 | 0% | $263 |
| Physical Therapy - Neuromuscular Reeducation | $75 | 0% | $75 |
| Physical Therapy - Self-care or Home Management Training | $75 | 0% | $75 |
| Physical Therapy - Therapeutic Activities | $70 | 0% | $70 |
| Physical Therapy - Therapeutic Exercises | $75 | 0% | $75 |
| Physical Therapy - Ultrasound Therapy | $75 | 0% | $75 |
| Psychiatric Diagnostic Evaluation | $209 | 0% | $209 |
| Psychotherapy - 30 Minutes | $71 | 0% | $71 |
| Psychotherapy - 45 Minutes | $104 | 0% | $104 |
| Psychotherapy - Group Session | $62 | 0% | $62 |
| Strep Test (Streptococcus, group A) | $62 | 0% | $62 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $60 | 0% | $60 |
| Ultrasound - Abdominal, Complete | $698 | 0% | $698 |
| Ultrasound - Abdominal, Limited | $521 | 0% | $521 |
| Ultrasound - Breast (outpatient) | $1,350 | 0% | $1,350 |
| Ultrasound - Head and Neck | $707 | 0% | $707 |
| Ultrasound - Pregnancy (outpatient) | $792 | 0% | $792 |
| Ultrasound - Pregnancy Follow-Up | $953 | 0% | $953 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,502 | 0% | $5,502 |
| Urine Test - Automated with Microscope Examination | $44 | 0% | $44 |
| Urine Test - Automated without Microscope | $33 | 0% | $33 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $48 | 0% | $48 |
| Urine Test - Chlamydia | $156 | 0% | $156 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $156 | 0% | $156 |
| Urine Test - Microalbumin (Protein) Level | $74 | 0% | $74 |
| Urine Test - Pregnancy | $36 | 0% | $36 |
| Urine Test - Urinalysis, Manual Test | $18 | 0% | $18 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $298 | 0% | $298 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $62 | 0% | $62 |
| X-Ray - Abdomen | $479 | 0% | $479 |
| X-Ray - Ankle (outpatient) | $436 | 0% | $436 |
| X-Ray - Chest (outpatient) | $503 | 0% | $503 |
| X-Ray - Foot (outpatient) | $459 | 0% | $459 |
| X-Ray - Hand | $466 | 0% | $466 |
| X-Ray - Hip | $382 | 0% | $382 |
| X-Ray - Knee (outpatient) | $486 | 0% | $486 |
| X-Ray - Neck, Cervical Spine | $377 | 0% | $377 |
| X-Ray - Pelvis | $535 | 0% | $535 |
| X-Ray - Shoulder (outpatient) | $597 | 0% | $597 |
| X-Ray - Spine (outpatient) | $614 | 0% | $614 |
| X-Ray - Wrist (outpatient) | $474 | 0% | $474 |
