| Ambulance Service - Emergency Transport, Advanced Life Support | $987 | N/A | $99 |
| Ambulance Service - Emergency Transport, Basic Life Support | $905 | N/A | $91 |
| Ambulance Service - Mileage Rate for Ambulance Transport | $22 | N/A | $2 |
| Arthrocentesis (outpatient) | $484 | N/A | $48 |
| Arthroscopic Knee Surgery (outpatient) | $13,768 | N/A | $1,377 |
| Arthroscopic Shoulder Surgery | $39,889 | N/A | $3,989 |
| Bacterial Culture - Aerobic Isolates | $95 | N/A | $9 |
| Biopsy - Punch Biopsy of Skin | $551 | N/A | $55 |
| Blood Test - Basic Metabolic Panel | $159 | N/A | $16 |
| Blood Test - Blood Glucose (Sugar) Level | $39 | N/A | $4 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $90 | N/A | $9 |
| Blood Test - C-reactive Protein (CRP) Level | $69 | N/A | $7 |
| Blood Test - Cholesterol Test, Lipid Panel | $103 | N/A | $10 |
| Blood Test - Clotting Time | $45 | N/A | $5 |
| Blood Test - Coagulation Assessment | $102 | N/A | $10 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $58 | N/A | $6 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $89 | N/A | $9 |
| Blood Test - Comprehensive Metabolic Panel | $207 | N/A | $21 |
| Blood Test - Creatinine Level | $37 | N/A | $4 |
| Blood Test - Electrolytes Panel | $102 | N/A | $10 |
| Blood Test - Ferritin (Blood Protein) Level | $166 | N/A | $17 |
| Blood Test - Folic Acid Level | $92 | N/A | $9 |
| Blood Test - General Health Panel | $190 | N/A | $19 |
| Blood Test - Hepatic (Liver) Function Panel | $76 | N/A | $8 |
| Blood Test - Hepatitis B Surface Antibody Level | $234 | N/A | $23 |
| Blood Test - Hepatitis C Antibody Level | $106 | N/A | $11 |
| Blood Test - Iron Binding Capacity | $67 | N/A | $7 |
| Blood Test - Iron Level | $58 | N/A | $6 |
| Blood Test - LDL Cholesterol Level | $58 | N/A | $6 |
| Blood Test - Lead Level | $58 | N/A | $6 |
| Blood Test - Lipase (fat enzyme) Level | $83 | N/A | $8 |
| Blood Test - Magnesium Level | $75 | N/A | $7 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $129 | N/A | $13 |
| Blood Test - Renal (Kidney) Function Panel | $101 | N/A | $10 |
| Blood Test - Thyroglobulin (Thyroid Protein) Antibody Level | $154 | N/A | $15 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $190 | N/A | $19 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $104 | N/A | $10 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $167 | N/A | $17 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $116 | N/A | $12 |
| Blood Test - Vitamin D-3 Level | $217 | N/A | $22 |
| Bone Density Scan (outpatient) | $573 | N/A | $57 |
| Colonoscopy - Diagnostic (outpatient) | $4,879 | N/A | $488 |
| Colonoscopy - With Biopsy (outpatient) | $8,366 | N/A | $837 |
| Colonoscopy - With Polyp Removal (outpatient) | $7,474 | N/A | $747 |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,866 | N/A | $387 |
| CT Scan - Chest, with Contrast (outpatient) | $2,670 | N/A | $267 |
| Destruction of Lesion (outpatient) | $523 | N/A | $52 |
| Developmental Screening | $33 | N/A | $3 |
| Electrocardiogram (ECG or EKG), Tracing | $551 | N/A | $55 |
| Electrocardiogram (ECG or EKG), with Report and Interpretation | $363 | N/A | $36 |
| Emergency Department Visit - Low Complexity (outpatient) | $356 | N/A | $36 |
| Emergency Department Visit - Minor (outpatient) | $208 | N/A | $21 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $553 | N/A | $55 |
| Fetal Non-Stress Test | $739 | N/A | $74 |
| Hydration Infusion | $87 | N/A | $9 |
| Lab Test - Creatinine Level | $59 | N/A | $6 |
| Lab Test - Detection for Strep (Streptococcus, group A) | $60 | N/A | $6 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $66 | N/A | $7 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $80 | N/A | $8 |
| Lab Test - Detection test for Influenza Virus | $104 | N/A | $10 |
| Lab Test - Smear for Microorganism | $58 | N/A | $6 |
| Mammogram (outpatient) | $1,062 | N/A | $106 |
| MRI - Back (outpatient) | $2,973 | N/A | $297 |
| MRI - Brain (outpatient) | $5,592 | N/A | $559 |
| MRI - Knee (outpatient) | $2,869 | N/A | $287 |
| Myocardial Imaging (outpatient) | $7,062 | N/A | $706 |
| Office Visit - Basic | $142 | N/A | $14 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 1-4 Years Old | $279 | N/A | $28 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 12-17 Years Old | $318 | N/A | $32 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $300 | N/A | $30 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $357 | N/A | $36 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $291 | N/A | $29 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $267 | N/A | $27 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $248 | N/A | $25 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $272 | N/A | $27 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $269 | N/A | $27 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $288 | N/A | $29 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $247 | N/A | $25 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $245 | N/A | $24 |
| Office Visit - Established Patient, High Complexity | $339 | N/A | $34 |
| Office Visit - Established Patient, Low Complexity | $171 | N/A | $17 |
| Office Visit - Established Patient, Moderate Complexity | $244 | N/A | $24 |
| Office Visit - New Patient, Low Complexity | $245 | N/A | $24 |
| Office Visit - New Patient, Minor | $176 | N/A | $18 |
| Office Visit - New Patient, Moderate Complexity | $372 | N/A | $37 |
| Physical Therapy - High Complexity Evaluation | $440 | 
Near Average
State Average: 1 | $44 |
| Physical Therapy - Low Complexity Evaluation | $204 |
Near Average
State Average: 1 | $20 |
| Physical Therapy - Manual Therapy | $119 | 
Below Average
State Average: 4 | $12 |
| Physical Therapy - Moderate Complexity Evaluation | $315 |
Near Average
State Average: 1 | $32 |
| Physical Therapy - Self-care or Home Management Training | $81 |
Near Average
State Average: 1 | $8 |
| Physical Therapy - Therapeutic Activities | $119 |
Below Average
State Average: 3 | $12 |
| Physical Therapy - Therapeutic Exercises | $119 |
Below Average
State Average: 4 | $12 |
| Physical Therapy - Ultrasound Therapy | $119 |
Below Average
State Average: 3 | $12 |
| Physical Therapy - Walking Training, 15 minutes | $83 |
Near Average
State Average: 1 | $8 |
| Psychiatric Diagnostic Evaluation | $137 |
Near Average
State Average: 1 | $14 |
| Psychotherapy - 30 Minutes | $89 | 
Above Average
State Average: 1 | $9 |
| Psychotherapy - 45 Minutes | $116 |
Below Average
State Average: 4 | $12 |
| Psychotherapy - 60 Minutes | $158 |
Near Average
State Average: 5 | $16 |
| Psychotherapy - Family Session | $189 |
Above Average
State Average: 3 | $19 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $63 | N/A | $6 |
| Ultrasound - Abdominal, Complete | $1,305 | N/A | $131 |
| Ultrasound - Abdominal, Limited | $927 | N/A | $93 |
| Ultrasound - Breast (outpatient) | $1,228 | N/A | $123 |
| Ultrasound - Head and Neck | $979 | N/A | $98 |
| Ultrasound - Pregnancy (outpatient) | $834 | N/A | $83 |
| Ultrasound - Pregnancy Follow-Up | $1,990 | N/A | $199 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,319 | N/A | $632 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $9,545 | N/A | $954 |
| Urine Test - Automated with Microscope Examination | $48 | N/A | $5 |
| Urine Test - Automated without Microscope | $37 | N/A | $4 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $91 | N/A | $9 |
| Urine Test - Chlamydia | $143 | N/A | $14 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $143 | N/A | $14 |
| Urine Test - Microalbumin (Protein) Level | $67 | N/A | $7 |
| Urine Test - Pregnancy | $74 | N/A | $7 |
| Urine Test - Urinalysis, Manual Test | $26 | N/A | $3 |
| Vaccine - Influenza for Injection into Muscle | $40 | N/A | $4 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $357 | N/A | $36 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $70 | N/A | $7 |
| X-Ray - Abdomen | $362 | N/A | $36 |
| X-Ray - Ankle (outpatient) | $537 | N/A | $54 |
| X-Ray - Chest (outpatient) | $664 | N/A | $66 |
| X-Ray - Foot (outpatient) | $560 | N/A | $56 |
| X-Ray - Hand | $588 | N/A | $59 |
| X-Ray - Hip | $274 | N/A | $27 |
| X-Ray - Knee (outpatient) | $593 | N/A | $59 |
| X-Ray - Middle Back, Thoracic Spine | $937 | N/A | $94 |
| X-Ray - Shoulder (outpatient) | $740 | N/A | $74 |
| X-Ray - Spine (outpatient) | $664 | N/A | $66 |
| X-Ray - Wrist (outpatient) | $537 | N/A | $54 |
