| Ambulance Service - Emergency Transport, Advanced Life Support | $1,750 | 58% | $735 |
| Arthrocentesis (outpatient) | $1,782 | 58% | $748 |
| Arthroscopic Knee Surgery (outpatient) | $14,676 | 58% | $6,164 |
| Arthroscopic Shoulder Surgery | $35,932 | 58% | $15,092 |
| Bacterial Culture - Aerobic Isolates | $98 | 58% | $41 |
| Bacterial Culture - Swab | $130 | 58% | $54 |
| Biopsy - Breast | $8,824 | 58% | $3,706 |
| Biopsy - Endometrial (Uterus) | $1,631 | 58% | $685 |
| Blood Test - Basic Metabolic Panel | $141 | 58% | $59 |
| Blood Test - Clotting Time | $87 | 58% | $37 |
| Blood Test - Coagulation Assessment | $119 | 58% | $50 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $127 | 58% | $53 |
| Blood Test - Comprehensive Metabolic Panel | $170 | 58% | $71 |
| Blood Test - Electrolytes Panel | $118 | 58% | $49 |
| Blood Test - General Health Panel | $330 | 58% | $138 |
| Blood Test - Hepatic (Liver) Function Panel | $167 | 58% | $70 |
| Blood Test - Lipase (fat enzyme) Level | $137 | 58% | $58 |
| Blood Test - Pregnancy (Obstetric) Panel | $271 | 58% | $114 |
| Blood Test - Renal (Kidney) Function Panel | $241 | 58% | $101 |
| Bone Density Scan (outpatient) | $610 | 58% | $256 |
| Colonoscopy - Diagnostic (outpatient) | $4,406 | 58% | $1,850 |
| Colonoscopy - With Biopsy (outpatient) | $5,704 | 58% | $2,396 |
| Colonoscopy - With Polyp Removal (outpatient) | $6,467 | 58% | $2,716 |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,800 | 58% | $2,856 |
| CT Scan - Chest, with Contrast (outpatient) | $3,908 | 58% | $1,642 |
| CT Scan - Head/Brain, without Contrast | $2,748 | 58% | $1,154 |
| Cystoscopy | $8,297 | 58% | $3,485 |
| Emergency Department Visit - Low Complexity (outpatient) | $630 | 58% | $265 |
| Emergency Department Visit - Minor (outpatient) | $350 | 58% | $147 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,081 | 58% | $454 |
| Fetal Non-Stress Test | $1,426 | 58% | $599 |
| Gall Bladder Surgery (outpatient) | $25,793 | 58% | $10,833 |
| Hernia Repair - Laparoscopic (outpatient) | $24,647 | 58% | $10,352 |
| Kidney Stone Removal (outpatient) | $12,836 | 58% | $5,391 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $209 | 58% | $88 |
| Mammogram (outpatient) | $916 | 58% | $385 |
| MRI - Back (outpatient) | $3,996 | 58% | $1,678 |
| MRI - Brain (outpatient) | $5,715 | 58% | $2,400 |
| MRI - Knee (outpatient) | $3,485 | 58% | $1,464 |
| MRI - Pelvis (outpatient) | $5,224 | 58% | $2,194 |
| MRI - Shoulder, Elbow, or Wrist | $3,466 | 58% | $1,456 |
| Myocardial Imaging (outpatient) | $9,995 | 58% | $4,198 |
| Office Visit - Established Patient, Low Complexity | $214 | 58% | $90 |
| Office Visit - Established Patient, Moderate Complexity | $326 | 58% | $137 |
| Physical Therapy - High Complexity Evaluation | $356 | 58% | $150 |
| Physical Therapy - Low Complexity Evaluation | $356 | 58% | $150 |
| Physical Therapy - Manual Therapy | $143 | 58% | $60 |
| Physical Therapy - Moderate Complexity Evaluation | $356 | 58% | $150 |
| Physical Therapy - Re-Evaluation | $202 | 58% | $85 |
| Physical Therapy - Self-care or Home Management Training | $135 | 58% | $57 |
| Physical Therapy - Therapeutic Activities | $148 | 58% | $62 |
| Physical Therapy - Therapeutic Exercises | $139 | 58% | $58 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $85 | 58% | $36 |
| Tonsillectomy with Adenoidectomy (outpatient) | $12,628 | 58% | $5,304 |
| Ultrasound - Abdominal, Complete | $1,245 | 58% | $523 |
| Ultrasound - Abdominal, Limited | $961 | 58% | $404 |
| Ultrasound - Breast (outpatient) | $1,521 | 58% | $639 |
| Ultrasound - Head and Neck | $902 | 58% | $379 |
| Ultrasound - Pelvic (outpatient) | $1,083 | 58% | $455 |
| Ultrasound - Pregnancy (outpatient) | $1,353 | 58% | $568 |
| Ultrasound - Pregnancy Follow-Up | $1,517 | 58% | $637 |
| Ultrasound - Transvaginal (non-maternity) | $1,038 | 58% | $436 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $5,137 | 58% | $2,157 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $5,744 | 58% | $2,412 |
| Urine Capacity Measurement | $710 | 58% | $298 |
| Urine Test - Automated with Microscope Examination | $109 | 58% | $46 |
| Urine Test - Automated without Microscope | $45 | 58% | $19 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $90 | 58% | $38 |
| Urine Test - Microalbumin (Protein) Level | $80 | 58% | $33 |
| Urine Test - Pregnancy | $153 | 58% | $64 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $554 | 58% | $233 |
| X-Ray - Abdomen | $712 | 58% | $299 |
| X-Ray - Ankle (outpatient) | $620 | 58% | $260 |
| X-Ray - Chest (outpatient) | $730 | 58% | $307 |
| X-Ray - Foot (outpatient) | $631 | 58% | $265 |
| X-Ray - Hand | $746 | 58% | $313 |
| X-Ray - Hip | $733 | 58% | $308 |
| X-Ray - Knee (outpatient) | $827 | 58% | $347 |
| X-Ray - Middle Back, Thoracic Spine | $778 | 58% | $327 |
| X-Ray - Neck, Cervical Spine | $794 | 58% | $333 |
| X-Ray - Pelvis | $1,152 | 58% | $484 |
| X-Ray - Shoulder (outpatient) | $639 | 58% | $268 |
| X-Ray - Spine (outpatient) | $654 | 58% | $275 |
| X-Ray - Wrist (outpatient) | $614 | 58% | $258 |
