| Ambulance Service - Emergency Transport, Advanced Life Support | $1,651 | 58% | $694 | 
Medium |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $1,588 | 58% | $667 |
Medium |
| Arthrocentesis (outpatient) | $1,974 | 58% | $829 |
Medium |
| Arthroscopic Knee Surgery (outpatient) | $13,630 | 58% | $5,725 |
Medium |
| Arthroscopic Shoulder Surgery | $31,745 | 58% | $13,333 |
Medium |
| Biopsy - Breast | $6,456 | 58% | $2,711 | 
High |
| Biopsy - Endometrial (Uterus) | $1,645 | 58% | $691 |
Medium |
| Blood Test - Basic Metabolic Panel | $133 | 58% | $56 |
Medium |
| Blood Test - Clotting Time | $82 | 58% | $34 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $120 | 58% | $50 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $160 | 58% | $67 |
Medium |
| Blood Test - Electrolytes Panel | $111 | 58% | $47 |
Medium |
| Blood Test - General Health Panel | $266 | 58% | $112 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $157 | 58% | $66 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $228 | 58% | $96 |
Medium |
| Blood Test - Vitamin D-3 Level | $412 | 58% | $173 |
Medium |
| Bone Density Scan (outpatient) | $578 | 58% | $243 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $4,325 | 58% | $1,816 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $5,864 | 58% | $2,463 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $6,368 | 58% | $2,674 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,439 | 58% | $2,704 |
Medium |
| CT Scan - Chest, with Contrast (outpatient) | $3,703 | 58% | $1,555 |
Medium |
| CT Scan - Head/Brain, without Contrast | $2,510 | 58% | $1,054 |
Medium |
| Cystoscopy | $3,368 | 58% | $1,415 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $300 | 58% | $126 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $215 | 58% | $90 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $585 | 58% | $246 |
Medium |
| Fetal Non-Stress Test | $1,346 | 58% | $565 |
Medium |
| Gall Bladder Surgery (outpatient) | $20,982 | 58% | $8,813 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $23,828 | 58% | $10,008 |
Medium |
| Kidney Stone Removal (outpatient) | $16,031 | 58% | $6,733 |
Medium |
| Mammogram (outpatient) | $879 | 58% | $369 |
Medium |
| MRI - Back (outpatient) | $3,789 | 58% | $1,591 |
Medium |
| MRI - Brain (outpatient) | $5,340 | 58% | $2,243 |
Medium |
| MRI - Knee (outpatient) | $3,304 | 58% | $1,388 |
Medium |
| MRI - Pelvis (outpatient) | $4,957 | 58% | $2,082 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $3,287 | 58% | $1,380 |
Medium |
| Myocardial Imaging (outpatient) | $9,054 | 58% | $3,803 |
Medium |
| Office Visit - Established Patient, Low Complexity | $206 | 58% | $86 |
Medium |
| Office Visit - Established Patient, Moderate Complexity | $316 | 58% | $133 |
Medium |
| Physical Therapy - High Complexity Evaluation | $336 | 58% | $141 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $336 | 58% | $141 |
Medium |
| Physical Therapy - Manual Therapy | $135 | 58% | $57 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $336 | 58% | $141 |
Medium |
| Physical Therapy - Therapeutic Activities | $140 | 58% | $59 |
Medium |
| Physical Therapy - Therapeutic Exercises | $131 | 58% | $55 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $80 | 58% | $34 |
Medium |
| Tonsillectomy with Adenoidectomy (outpatient) | $10,699 | 58% | $4,494 |
Medium |
| Ultrasound - Abdominal, Complete | $1,184 | 58% | $497 |
Medium |
| Ultrasound - Abdominal, Limited | $914 | 58% | $384 |
Medium |
| Ultrasound - Breast (outpatient) | $1,456 | 58% | $611 |
High |
| Ultrasound - Head and Neck | $857 | 58% | $360 |
Medium |
| Ultrasound - Pelvic (outpatient) | $1,030 | 58% | $433 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $1,289 | 58% | $541 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $1,328 | 58% | $558 |
Medium |
| Ultrasound - Transvaginal (non-maternity) | $971 | 58% | $408 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $5,412 | 58% | $2,273 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $6,467 | 58% | $2,716 |
Medium |
| Urine Capacity Measurement | $1,124 | 58% | $472 |
Medium |
| Urine Test - Automated with Microscope Examination | $103 | 58% | $43 |
Medium |
| Urine Test - Automated without Microscope | $43 | 58% | $18 |
Medium |
| Urine Test - Bacterial Culture | $85 | 58% | $36 |
Medium |
| Urine Test - Pregnancy | $144 | 58% | $60 |
Medium |
| X-Ray - Abdomen | $647 | 58% | $272 |
High |
| X-Ray - Ankle (outpatient) | $597 | 58% | $251 |
Medium |
| X-Ray - Chest (outpatient) | $691 | 58% | $290 |
Medium |
| X-Ray - Foot (outpatient) | $591 | 58% | $248 |
Medium |
| X-Ray - Hand | $642 | 58% | $270 |
Medium |
| X-Ray - Hip | $724 | 58% | $304 |
Medium |
| X-Ray - Knee (outpatient) | $701 | 58% | $295 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $647 | 58% | $272 |
Medium |
| X-Ray - Neck, Cervical Spine | $764 | 58% | $321 |
Medium |
| X-Ray - Pelvis | $845 | 58% | $355 |
Medium |
| X-Ray - Shoulder (outpatient) | $602 | 58% | $253 |
Medium |
| X-Ray - Spine (outpatient) | $654 | 58% | $275 |
Medium |
| X-Ray - Wrist (outpatient) | $591 | 58% | $248 |
Medium |
