| Ambulance Service - Emergency Transport, Advanced Life Support | $1,326 | 40% | $795 | 
Medium |
| Ambulance Service - Emergency Transport, Basic Life Support | $1,039 | 40% | $623 |
Medium |
| Ambulance Service - Mileage Rate for Ambulance Transport | $36 | 40% | $21 |
Medium |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $764 | 40% | $459 |
Medium |
| Blood Test - Basic Metabolic Panel | $16 | 40% | $9 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $19 | 40% | $11 |
Medium |
| Blood Test - Cholesterol Test, Lipid Panel | $26 | 40% | $16 |
Medium |
| Blood Test - Clotting Time | $7 | 40% | $4 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $13 | 40% | $8 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $15 | 40% | $9 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $20 | 40% | $12 |
Medium |
| Blood Test - Electrolytes Panel | $14 | 40% | $8 |
Medium |
| Blood Test - General Health Panel | $67 | 40% | $40 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $16 | 40% | $9 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $28 | 40% | $17 |
Medium |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $33 | 40% | $20 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $17 | 40% | $10 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $23 | 40% | $14 |
Medium |
| Blood Test - Vitamin D-3 Level | $56 | 40% | $33 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $8,257 | 40% | $4,954 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $8,855 | 40% | $5,313 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $2,043 | 40% | $1,226 |
Medium |
| CT Scan - Chest, with Contrast (outpatient) | $2,326 | 40% | $1,395 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $716 | 40% | $430 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $426 | 40% | $256 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,838 | 40% | $1,103 |
Medium |
| Mammogram (outpatient) | $761 | 40% | $457 |
Medium |
| MRI - Back (outpatient) | $2,844 | 40% | $1,707 |
Medium |
| MRI - Brain (outpatient) | $4,493 | 40% | $2,696 |
Medium |
| Physical Therapy - High Complexity Evaluation | $378 | 40% | $227 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $378 | 40% | $227 |
Medium |
| Physical Therapy - Manual Therapy | $90 | 40% | $54 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $378 | 40% | $227 |
Medium |
| Physical Therapy - Re-Evaluation | $202 | 40% | $121 |
Medium |
| Physical Therapy - Therapeutic Exercises | $90 | 40% | $54 |
Medium |
| Physical Therapy - Ultrasound Therapy | $90 | 40% | $54 |
Medium |
| Strep Test (Streptococcus, group A) | $22 | 40% | $13 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $12 | 40% | $7 |
Medium |
| Ultrasound - Abdominal, Complete | $775 | 40% | $465 |
Medium |
| Ultrasound - Abdominal, Limited | $728 | 40% | $437 |
Medium |
| Ultrasound - Breast (outpatient) | $652 | 40% | $391 |
Medium |
| Ultrasound - Head and Neck | $720 | 40% | $432 |
Medium |
| Urine Test - Automated with Microscope Examination | $6 | 40% | $4 |
Medium |
| Urine Test - Automated without Microscope | $3 | 40% | $2 |
Medium |
| Urine Test - Bacterial Culture | $13 | 40% | $8 |
Medium |
| Urine Test - Chlamydia | $48 | 40% | $29 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $49 | 40% | $30 |
Medium |
| Urine Test - Pregnancy | $13 | 40% | $8 |
Medium |
| X-Ray - Abdomen | $247 | 40% | $148 |
Medium |
| X-Ray - Chest (outpatient) | $387 | 40% | $232 |
Medium |
| X-Ray - Foot (outpatient) | $364 | 40% | $219 |
Medium |
| X-Ray - Hip | $353 | 40% | $212 |
Medium |
| X-Ray - Knee (outpatient) | $202 | 40% | $121 |
Medium |
| X-Ray - Shoulder (outpatient) | $380 | 40% | $228 | 
High |
| X-Ray - Spine (outpatient) | $485 | 40% | $291 |
Medium |
