| Ambulance Service - Emergency Transport, Advanced Life Support | $987 | 50% | $494 |
| Ambulance Service - Emergency Transport, Basic Life Support | $905 | 50% | $453 |
| Ambulance Service - Mileage Rate for Ambulance Transport | $22 | 50% | $11 |
| Arthrocentesis (outpatient) | $600 | 50% | $300 |
| Arthroscopic Knee Surgery (outpatient) | $12,646 | 50% | $6,323 |
| Bacterial Culture - Aerobic Isolates | $95 | 50% | $47 |
| Bacterial Culture - Swab | $109 | 50% | $55 |
| Biopsy - Punch Biopsy of Skin | $515 | 50% | $258 |
| Blood Test - Basic Metabolic Panel | $159 | 50% | $79 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $90 | 50% | $45 |
| Blood Test - Cholesterol Test, Lipid Panel | $103 | 50% | $51 |
| Blood Test - Clotting Time | $45 | 50% | $23 |
| Blood Test - Coagulation Assessment | $102 | 50% | $51 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $56 | 50% | $28 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $89 | 50% | $45 |
| Blood Test - Comprehensive Metabolic Panel | $207 | 50% | $103 |
| Blood Test - Electrolytes Panel | $102 | 50% | $51 |
| Blood Test - Ferritin (Blood Protein) Level | $166 | 50% | $83 |
| Blood Test - Folic Acid Level | $92 | 50% | $46 |
| Blood Test - General Health Panel | $190 | 50% | $95 |
| Blood Test - Hepatic (Liver) Function Panel | $74 | 50% | $37 |
| Blood Test - Hepatitis C Antibody Level | $106 | 50% | $53 |
| Blood Test - Iron Level | $58 | 50% | $29 |
| Blood Test - LDL Cholesterol Level | $58 | 50% | $29 |
| Blood Test - Lipase (fat enzyme) Level | $81 | 50% | $40 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $129 | 50% | $65 |
| Blood Test - Renal (Kidney) Function Panel | $98 | 50% | $49 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $190 | 50% | $95 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $104 | 50% | $52 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $167 | 50% | $83 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $116 | 50% | $58 |
| Blood Test - Vitamin D-3 Level | $217 | 50% | $109 |
| Bone Density Scan (outpatient) | $573 | 50% | $287 |
| Colonoscopy - Diagnostic (outpatient) | $4,775 | 50% | $2,388 |
| Colonoscopy - With Biopsy (outpatient) | $7,998 | 50% | $3,999 |
| Colonoscopy - With Polyp Removal (outpatient) | $7,175 | 50% | $3,587 |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,772 | 50% | $1,886 |
| CT Scan - Chest, with Contrast (outpatient) | $2,615 | 50% | $1,307 |
| CT Scan - Head/Brain, without Contrast | $2,288 | 50% | $1,144 |
| Destruction of Lesion (outpatient) | $489 | 50% | $245 |
| Electrocardiogram (ECG or EKG) | $502 | 50% | $251 |
| Emergency Department Visit - Low Complexity (outpatient) | $356 | 50% | $178 |
| Emergency Department Visit - Minor (outpatient) | $202 | 50% | $101 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $553 | 50% | $277 |
| Fetal Non-Stress Test | $1,308 | 50% | $654 |
| Gall Bladder Surgery (outpatient) | $24,263 | 50% | $12,131 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $66 | 50% | $33 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $80 | 50% | $40 |
| Lab Test - Detection test for Influenza Virus | $101 | 50% | $50 |
| Lab Test - Smear for Microorganism | $58 | 50% | $29 |
| Mammogram (outpatient) | $1,058 | 50% | $529 |
| MRI - Back (outpatient) | $2,895 | 50% | $1,447 |
| MRI - Brain (outpatient) | $5,443 | 50% | $2,722 |
| MRI - Knee (outpatient) | $2,869 | 50% | $1,434 |
| MRI - Pelvis (outpatient) | $5,498 | 50% | $2,749 |
| MRI - Shoulder, Elbow, or Wrist | $2,869 | 50% | $1,434 |
| Myocardial Imaging (outpatient) | $5,441 | 50% | $2,721 |
| Office Visit - Basic | $142 | 50% | $71 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $279 | 50% | $140 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $318 | 50% | $159 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $300 | 50% | $150 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $347 | 50% | $173 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $281 | 50% | $141 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $251 | 50% | $125 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $240 | 50% | $120 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $264 | 50% | $132 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $269 | 50% | $134 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $288 | 50% | $144 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $239 | 50% | $120 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $226 | 50% | $113 |
| Office Visit - Established Patient, High Complexity | $330 | 50% | $165 |
| Office Visit - Established Patient, Low Complexity | $171 | 50% | $86 |
| Office Visit - Established Patient, Moderate Complexity | $244 | 50% | $122 |
| Office Visit - New Patient, Low Complexity | $245 | 50% | $122 |
| Office Visit - New Patient, Minor | $176 | 50% | $88 |
| Office Visit - New Patient, Moderate Complexity | $373 | 50% | $186 |
| Physical Therapy - High Complexity Evaluation | $440 | 50% | $220 |
| Physical Therapy - Low Complexity Evaluation | $204 | 50% | $102 |
| Physical Therapy - Manual Therapy | $119 | 50% | $59 |
| Physical Therapy - Moderate Complexity Evaluation | $315 | 50% | $158 |
| Physical Therapy - Self-care or Home Management Training | $81 | 50% | $40 |
| Physical Therapy - Therapeutic Activities | $119 | 50% | $59 |
| Physical Therapy - Therapeutic Exercises | $119 | 50% | $59 |
| Physical Therapy - Ultrasound Therapy | $119 | 50% | $59 |
| Psychiatric Diagnostic Evaluation | $137 | 50% | $68 |
| Psychotherapy - 30 Minutes | $89 | 50% | $45 |
| Psychotherapy - 45 Minutes | $112 | 50% | $56 |
| Psychotherapy - 60 Minutes | $158 | 50% | $79 |
| Psychotherapy - Family Session | $189 | 50% | $95 |
| Strep Test (Streptococcus, group A) | $60 | 50% | $30 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $61 | 50% | $30 |
| Tonsillectomy with Adenoidectomy (outpatient) | $17,524 | 50% | $8,762 |
| Ultrasound - Abdominal, Complete | $1,305 | 50% | $653 |
| Ultrasound - Abdominal, Limited | $884 | 50% | $442 |
| Ultrasound - Breast (outpatient) | $935 | 50% | $467 |
| Ultrasound - Head and Neck | $979 | 50% | $489 |
| Ultrasound - Pelvic (outpatient) | $855 | 50% | $427 |
| Ultrasound - Pregnancy (outpatient) | $834 | 50% | $417 |
| Ultrasound - Pregnancy Follow-Up | $1,844 | 50% | $922 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,307 | 50% | $3,153 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,789 | 50% | $4,395 |
| Urine Test - Automated with Microscope Examination | $47 | 50% | $24 |
| Urine Test - Automated without Microscope | $37 | 50% | $18 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $91 | 50% | $46 |
| Urine Test - Chlamydia | $143 | 50% | $71 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $143 | 50% | $71 |
| Urine Test - Microalbumin (Protein) Level | $67 | 50% | $34 |
| Urine Test - Pregnancy | $74 | 50% | $37 |
| Urine Test - Urinalysis, Manual Test | $26 | 50% | $13 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $357 | 50% | $179 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $70 | 50% | $35 |
| X-Ray - Abdomen | $500 | 50% | $250 |
| X-Ray - Ankle (outpatient) | $537 | 50% | $268 |
| X-Ray - Chest (outpatient) | $664 | 50% | $332 |
| X-Ray - Foot (outpatient) | $544 | 50% | $272 |
| X-Ray - Hand | $577 | 50% | $288 |
| X-Ray - Hip | $388 | 50% | $194 |
| X-Ray - Knee (outpatient) | $560 | 50% | $280 |
| X-Ray - Middle Back, Thoracic Spine | $907 | 50% | $454 |
| X-Ray - Shoulder (outpatient) | $673 | 50% | $337 |
| X-Ray - Spine (outpatient) | $591 | 50% | $296 |
| X-Ray - Wrist (outpatient) | $537 | 50% | $268 |
