| Ambulance Service - Emergency Transport, Advanced Life Support | $1,022 | 0% | $1,022 |
| Ambulance Service - Mileage Rate for Ambulance Transport | $28 | 0% | $28 |
| Arthrocentesis (outpatient) | $1,708 | 0% | $1,708 |
| Bacterial Culture - Aerobic Isolates | $93 | 0% | $93 |
| Bacterial Culture - Swab | $175 | 0% | $175 |
| Biopsy - Breast | $5,942 | 0% | $5,942 |
| Biopsy - Endometrial (Uterus) | $1,135 | 0% | $1,135 |
| Blood Test - Basic Metabolic Panel | $139 | 0% | $139 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $93 | 0% | $93 |
| Blood Test - Cholesterol Test, Lipid Panel | $159 | 0% | $159 |
| Blood Test - Clotting Time | $80 | 0% | $80 |
| Blood Test - Coagulation Assessment | $159 | 0% | $159 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $83 | 0% | $83 |
| Blood Test - Comprehensive Metabolic Panel | $159 | 0% | $159 |
| Blood Test - Electrolytes Panel | $124 | 0% | $124 |
| Blood Test - Ferritin (Blood Protein) Level | $124 | 0% | $124 |
| Blood Test - General Health Panel | $271 | 0% | $271 |
| Blood Test - Hepatic (Liver) Function Panel | $131 | 0% | $131 |
| Blood Test - Hepatitis C Antibody Level | $168 | 0% | $168 |
| Blood Test - Iron Level | $101 | 0% | $101 |
| Blood Test - Lipase (fat enzyme) Level | $67 | 0% | $67 |
| Blood Test - Pregnancy (Obstetric) Panel | $250 | 0% | $250 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $106 | 0% | $106 |
| Blood Test - Renal (Kidney) Function Panel | $131 | 0% | $131 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $175 | 0% | $175 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $205 | 0% | $205 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $238 | 0% | $238 |
| Blood Test - Vitamin D-3 Level | $86 | 0% | $86 |
| Bone Density Scan (outpatient) | $628 | 0% | $628 |
| Colonoscopy - With Biopsy (outpatient) | $4,457 | 0% | $4,457 |
| CT Scan - Abdomen and Pelvis, with Contrast | $4,954 | 0% | $4,954 |
| CT Scan - Chest, with Contrast (outpatient) | $2,498 | 0% | $2,498 |
| CT Scan - Head/Brain, without Contrast | $1,918 | 0% | $1,918 |
| Electrocardiogram (ECG or EKG) | $1,659 | 0% | $1,659 |
| Emergency Department Visit - Low Complexity (outpatient) | $439 | 0% | $439 |
| Emergency Department Visit - Minor (outpatient) | $277 | 0% | $277 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $610 | 0% | $610 |
| Fetal Non-Stress Test | $1,422 | 0% | $1,422 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $168 | 0% | $168 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $101 | 0% | $101 |
| Lab Test - Detection test for Influenza Virus | $53 | 0% | $53 |
| Lab Test - Smear for Microorganism | $67 | 0% | $67 |
| Mammogram (outpatient) | $1,065 | 0% | $1,065 |
| Myocardial Imaging (outpatient) | $5,184 | 0% | $5,184 |
| Office Visit - Basic | $144 | 0% | $144 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $401 | 0% | $401 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $453 | 0% | $453 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 5-11 Years Old | $394 | 0% | $394 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, Younger than 1 Year Old | $307 | 0% | $307 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $341 | 0% | $341 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 12-17 Years Old | $360 | 0% | $360 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $373 | 0% | $373 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $394 | 0% | $394 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 5-11 Years Old | $341 | 0% | $341 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, Younger than 1 Year Old | $302 | 0% | $302 |
| Office Visit - Established Patient, Low Complexity | $201 | 0% | $201 |
| Office Visit - Established Patient, Moderate Complexity | $346 | 0% | $346 |
| Office Visit - New Patient, Low Complexity | $340 | 0% | $340 |
| Office Visit - New Patient, Minor | $231 | 0% | $231 |
| Physical Therapy - Manual Therapy | $147 | 0% | $147 |
| Physical Therapy - Therapeutic Exercises | $147 | 0% | $147 |
| Strep Test (Streptococcus, group A) | $53 | 0% | $53 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $139 | 0% | $139 |
| Ultrasound - Abdominal, Complete | $1,370 | 0% | $1,370 |
| Ultrasound - Abdominal, Limited | $981 | 0% | $981 |
| Ultrasound - Breast (outpatient) | $2,231 | 0% | $2,231 |
| Ultrasound - Head and Neck | $811 | 0% | $811 |
| Ultrasound - Pelvic (outpatient) | $884 | 0% | $884 |
| Ultrasound - Pregnancy (outpatient) | $1,010 | 0% | $1,010 |
| Ultrasound - Pregnancy Follow-Up | $765 | 0% | $765 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $4,184 | 0% | $4,184 |
| Urine Test - Automated with Microscope Examination | $80 | 0% | $80 |
| Urine Test - Automated without Microscope | $80 | 0% | $80 |
| Urine Test - Chlamydia | $185 | 0% | $185 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $185 | 0% | $185 |
| Urine Test - Microalbumin (Protein) Level | $48 | 0% | $48 |
| Urine Test - Pregnancy | $101 | 0% | $101 |
| Urine Test - Urinalysis, Manual Test | $44 | 0% | $44 |
| Vaccine - Pneumococcal Conjugate for Injection into Muscle | $322 | 0% | $322 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $123 | 0% | $123 |
| X-Ray - Abdomen | $1,387 | 0% | $1,387 |
| X-Ray - Ankle (outpatient) | $635 | 0% | $635 |
| X-Ray - Chest (outpatient) | $734 | 0% | $734 |
| X-Ray - Foot (outpatient) | $678 | 0% | $678 |
| X-Ray - Hand | $852 | 0% | $852 |
| X-Ray - Hip | $841 | 0% | $841 |
| X-Ray - Knee (outpatient) | $650 | 0% | $650 |
| X-Ray - Shoulder (outpatient) | $609 | 0% | $609 |
| X-Ray - Spine (outpatient) | $1,051 | 0% | $1,051 |
| X-Ray - Wrist (outpatient) | $677 | 0% | $677 |
