| Ambulance Service - Emergency Transport, Advanced Life Support | $1,701 | 58% | $714 | 
Medium |
| Arthrocentesis (outpatient) | $1,686 | 58% | $708 |
Medium |
| Arthroscopic Knee Surgery (outpatient) | $14,855 | 58% | $6,239 |
Medium |
| Arthroscopic Shoulder Surgery | $35,372 | 58% | $14,856 |
Medium |
| Bacterial Culture Swab | $130 | 58% | $54 |
Medium |
| Biopsy - Breast | $6,493 | 58% | $2,727 |
Medium |
| Biopsy - Endometrial (Uterus) | $1,756 | 58% | $738 | 
High |
| Blood Test - Basic Metabolic Panel | $141 | 58% | $59 |
Medium |
| Blood Test - Clotting Time | $87 | 58% | $37 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $127 | 58% | $53 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $170 | 58% | $71 |
Medium |
| Blood Test - Electrolytes Panel | $114 | 58% | $48 |
Medium |
| Blood Test - General Health Panel | $330 | 58% | $138 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $157 | 58% | $66 |
Medium |
| Blood Test - Lipase (fat enzyme) Level | $137 | 58% | $58 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $228 | 58% | $96 |
Medium |
| Bone Density Scan (outpatient) | $610 | 58% | $256 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $4,406 | 58% | $1,850 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $5,831 | 58% | $2,449 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $6,489 | 58% | $2,725 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,800 | 58% | $2,856 |
Medium |
| CT Scan - Chest, with Contrast (outpatient) | $3,908 | 58% | $1,642 |
Medium |
| CT Scan - Head/Brain, without Contrast | $2,649 | 58% | $1,113 |
High |
| Cystoscopy | $4,119 | 58% | $1,730 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $318 | 58% | $134 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $215 | 58% | $90 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $620 | 58% | $260 |
Medium |
| Fetal Non-Stress Test | $1,387 | 58% | $583 |
Medium |
| Gall Bladder Surgery (outpatient) | $18,549 | 58% | $7,790 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $24,078 | 58% | $10,113 |
Medium |
| Kidney Stone Removal (outpatient) | $13,866 | 58% | $5,824 |
Medium |
| Mammogram (outpatient) | $916 | 58% | $385 |
Medium |
| MRI - Back (outpatient) | $3,996 | 58% | $1,678 |
Medium |
| MRI - Brain (outpatient) | $5,630 | 58% | $2,364 |
Medium |
| MRI - Knee (outpatient) | $3,456 | 58% | $1,451 |
Medium |
| MRI - Pelvis (outpatient) | $5,038 | 58% | $2,116 |
Medium |
| MRI - Shoulder, Elbow, or Wrist | $3,466 | 58% | $1,456 |
Medium |
| Myocardial Imaging (outpatient) | $9,054 | 58% | $3,803 |
Medium |
| Office Visit - Established Patient, Low Complexity | $211 | 58% | $89 |
Medium |
| Office Visit - Established Patient, Moderate Complexity | $326 | 58% | $137 |
Medium |
| Physical Therapy - High Complexity Evaluation | $356 | 58% | $150 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $356 | 58% | $150 |
Medium |
| Physical Therapy - Manual Therapy | $143 | 58% | $60 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $356 | 58% | $150 |
Medium |
| Physical Therapy - Re-Evaluation | $202 | 58% | $85 |
Medium |
| Physical Therapy - Self-care or Home Management Training | $135 | 58% | $57 |
Medium |
| Physical Therapy - Therapeutic Activities | $148 | 58% | $62 |
Medium |
| Physical Therapy - Therapeutic Exercises | $139 | 58% | $58 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $85 | 58% | $36 |
Medium |
| Tonsillectomy with Adenoidectomy (outpatient) | $12,023 | 58% | $5,050 |
High |
| Ultrasound - Abdominal, Complete | $1,245 | 58% | $523 |
Medium |
| Ultrasound - Abdominal, Limited | $961 | 58% | $404 |
Medium |
| Ultrasound - Breast (outpatient) | $1,521 | 58% | $639 |
Medium |
| Ultrasound - Head and Neck | $902 | 58% | $379 |
Medium |
| Ultrasound - Pelvic (outpatient) | $1,083 | 58% | $455 |
High |
| Ultrasound - Pregnancy (outpatient) | $1,353 | 58% | $568 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $1,342 | 58% | $564 |
High |
| Ultrasound - Transvaginal (non-maternity) | $1,020 | 58% | $428 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $4,714 | 58% | $1,980 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $6,577 | 58% | $2,763 |
Medium |
| Urine Capacity Measurement | $704 | 58% | $296 |
Medium |
| Urine Test - Automated with Microscope Examination | $109 | 58% | $46 |
Medium |
| Urine Test - Automated without Microscope | $45 | 58% | $19 |
Medium |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $90 | 58% | $38 |
Medium |
| Urine Test - Pregnancy | $153 | 58% | $64 |
Medium |
| X-Ray - Abdomen | $680 | 58% | $285 |
Medium |
| X-Ray - Ankle (outpatient) | $601 | 58% | $253 |
Medium |
| X-Ray - Chest (outpatient) | $691 | 58% | $290 |
Medium |
| X-Ray - Foot (outpatient) | $614 | 58% | $258 |
Medium |
| X-Ray - Hand | $746 | 58% | $313 |
Medium |
| X-Ray - Hip | $741 | 58% | $311 |
Medium |
| X-Ray - Knee (outpatient) | $782 | 58% | $329 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $730 | 58% | $307 |
Medium |
| X-Ray - Neck, Cervical Spine | $767 | 58% | $322 |
Medium |
| X-Ray - Pelvis | $1,189 | 58% | $500 |
Medium |
| X-Ray - Shoulder (outpatient) | $625 | 58% | $263 |
Medium |
| X-Ray - Spine (outpatient) | $654 | 58% | $275 |
Medium |
| X-Ray - Wrist (outpatient) | $614 | 58% | $258 |
Medium |
