| Ambulance Service - Emergency Transport, Advanced Life Support | $1,298 | 0% | $1,298 |
| Ambulance Service - Emergency Transport, Basic Life Support | $840 | 0% | $840 |
| Ambulance Service - Mileage Rate for Ambulance Transport | $32 | 0% | $32 |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $735 | 0% | $735 |
| Bacterial Culture - Aerobic Isolates | $27 | 0% | $27 |
| Bacterial Culture - Swab | $53 | 0% | $53 |
| Blood Test - Basic Metabolic Panel | $56 | 0% | $56 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $65 | 0% | $65 |
| Blood Test - Cholesterol Test, Lipid Panel | $81 | 0% | $81 |
| Blood Test - Clotting Time | $40 | 0% | $40 |
| Blood Test - Coagulation Assessment | $50 | 0% | $50 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $32 | 0% | $32 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $57 | 0% | $57 |
| Blood Test - Comprehensive Metabolic Panel | $86 | 0% | $86 |
| Blood Test - Electrolytes Panel | $77 | 0% | $77 |
| Blood Test - Ferritin (Blood Protein) Level | $91 | 0% | $91 |
| Blood Test - Folic Acid Level | $89 | 0% | $89 |
| Blood Test - General Health Panel | $251 | 0% | $251 |
| Blood Test - Hepatic (Liver) Function Panel | $64 | 0% | $64 |
| Blood Test - Hepatitis C Antibody Level | $51 | 0% | $51 |
| Blood Test - Iron Level | $56 | 0% | $56 |
| Blood Test - LDL Cholesterol Level | $41 | 0% | $41 |
| Blood Test - Lipase (fat enzyme) Level | $47 | 0% | $47 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $99 | 0% | $99 |
| Blood Test - Renal (Kidney) Function Panel | $55 | 0% | $55 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $109 | 0% | $109 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $91 | 0% | $91 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $101 | 0% | $101 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $100 | 0% | $100 |
| Blood Test - Vitamin D-3 Level | $129 | 0% | $129 |
| Bone Density Scan (outpatient) | $491 | 0% | $491 |
| Colonoscopy - Diagnostic (outpatient) | $4,730 | 0% | $4,730 |
| Colonoscopy - With Biopsy (outpatient) | $6,048 | 0% | $6,048 |
| CT Scan - Abdomen and Pelvis, with Contrast | $3,800 | 0% | $3,800 |
| CT Scan - Chest, with Contrast (outpatient) | $2,228 | 0% | $2,228 |
| Detection test for Human Papillomavirus (HPV) | $376 | 0% | $376 |
| Emergency Department Visit - Low Complexity (outpatient) | $307 | 0% | $307 |
| Emergency Department Visit - Minor (outpatient) | $227 | 0% | $227 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $434 | 0% | $434 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $84 | 0% | $84 |
| Fetal Non-Stress Test | $1,165 | 0% | $1,165 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $45 | 0% | $45 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $92 | 0% | $92 |
| Lab Test - Smear for Microorganism | $40 | 0% | $40 |
| Mammogram (outpatient) | $899 | 0% | $899 |
| MRI - Back (outpatient) | $963 | 0% | $963 |
| MRI - Knee (outpatient) | $1,999 | 0% | $1,999 |
| Myocardial Imaging (outpatient) | $5,851 | 0% | $5,851 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $368 | 0% | $368 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $394 | 0% | $394 |
| Office Visit - Established Patient, Moderate Complexity | $315 | 0% | $315 |
| Physical Therapy - Application of Hot or Cold Pack | $69 | 0% | $69 |
| Physical Therapy - Low Complexity Evaluation | $160 | 0% | $160 |
| Physical Therapy - Manual Therapy | $105 | 0% | $105 |
| Physical Therapy - Moderate Complexity Evaluation | $172 | 0% | $172 |
| Physical Therapy - Neuromuscular Reeducation | $81 | 0% | $81 |
| Physical Therapy - Self-care or Home Management Training | $82 | 0% | $82 |
| Physical Therapy - Therapeutic Activities | $112 | 0% | $112 |
| Physical Therapy - Therapeutic Exercises | $98 | 0% | $98 |
| Physical Therapy - Ultrasound Therapy | $75 | 0% | $75 |
| Strep Test (Streptococcus, group A) | $76 | 0% | $76 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $41 | 0% | $41 |
| Ultrasound - Abdominal, Complete | $1,380 | 0% | $1,380 |
| Ultrasound - Abdominal, Limited | $742 | 0% | $742 |
| Ultrasound - Breast (outpatient) | $1,473 | 0% | $1,473 |
| Ultrasound - Head and Neck | $705 | 0% | $705 |
| Ultrasound - Pelvic (outpatient) | $882 | 0% | $882 |
| Ultrasound - Pregnancy Follow-Up | $669 | 0% | $669 |
| Ultrasound - Transvaginal (non-maternity) | $1,061 | 0% | $1,061 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $6,405 | 0% | $6,405 |
| Urine Test - Automated with Microscope Examination | $29 | 0% | $29 |
| Urine Test - Bacterial Culture | $45 | 0% | $45 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $67 | 0% | $67 |
| Urine Test - Chlamydia | $146 | 0% | $146 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $146 | 0% | $146 |
| Urine Test - Microalbumin (Protein) Level | $35 | 0% | $35 |
| Urine Test - Pregnancy | $33 | 0% | $33 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $111 | 0% | $111 |
| X-Ray - Chest (outpatient) | $598 | 0% | $598 |
| X-Ray - Foot (outpatient) | $637 | 0% | $637 |
| X-Ray - Knee (outpatient) | $362 | 0% | $362 |
| X-Ray - Neck, Cervical Spine | $756 | 0% | $756 |
| X-Ray - Spine (outpatient) | $666 | 0% | $666 |
