| Ambulance Service - Mileage Rate for Ambulance Transport | $37 | 58% | $15 | 
Medium |
| Ambulance Service - Non-Emergency Transport, Advanced Life Support | $956 | 58% | $401 |
Medium |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $665 | 58% | $279 |
Medium |
| Arthrocentesis (outpatient) | $1,970 | 58% | $827 |
Medium |
| Arthroscopic Knee Surgery (outpatient) | $20,551 | 58% | $8,631 |
Medium |
| Bacterial Culture Swab | $187 | 58% | $78 |
Medium |
| Biopsy - Breast | $4,842 | 58% | $2,033 |
Medium |
| Biopsy - Endometrial (Uterus) | $1,683 | 58% | $707 |
Medium |
| Biopsy - Skin Lesion | $1,516 | 58% | $637 |
Medium |
| Blood Test - Basic Metabolic Panel | $48 | 58% | $20 |
Medium |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $98 | 58% | $41 |
Medium |
| Blood Test - Cholesterol Test, Lipid Panel | $95 | 58% | $40 |
Medium |
| Blood Test - Clotting Time | $50 | 58% | $21 |
Medium |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $67 | 58% | $28 |
Medium |
| Blood Test - Complete Blood Cell Count and Automated WBC | $70 | 58% | $30 |
Medium |
| Blood Test - Comprehensive Metabolic Panel | $60 | 58% | $25 |
Medium |
| Blood Test - Electrolytes Panel | $37 | 58% | $15 |
Medium |
| Blood Test - Folic Acid Level | $101 | 58% | $42 |
Medium |
| Blood Test - General Health Panel | $225 | 58% | $94 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $54 | 58% | $22 |
Medium |
| Blood Test - Hepatitis C Antibody Level | $216 | 58% | $91 |
Medium |
| Blood Test - LDL Cholesterol Level | $66 | 58% | $28 |
Medium |
| Blood Test - Lipase (fat enzyme) Level | $30 | 58% | $13 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $112 | 58% | $47 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $78 | 58% | $33 |
Medium |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $95 | 58% | $40 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $111 | 58% | $47 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $97 | 58% | $41 |
Medium |
| Blood Test - Vitamin D-3 Level | $186 | 58% | $78 |
Medium |
| Bone Density Scan (outpatient) | $838 | 58% | $352 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $5,718 | 58% | $2,401 | 
High |
| Colonoscopy - With Biopsy (outpatient) | $7,768 | 58% | $3,262 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $8,604 | 58% | $3,614 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,894 | 58% | $2,896 |
Medium |
| CT Scan - Chest, with Contrast (outpatient) | $5,278 | 58% | $2,217 |
Medium |
| CT Scan - Head/Brain, without Contrast | $3,117 | 58% | $1,309 |
Medium |
| Cystoscopy | $3,471 | 58% | $1,458 |
Medium |
| Destruction of Lesion (outpatient) | $665 | 58% | $279 |
Medium |
| Destruction of Lesions, up to 14 | $655 | 58% | $275 |
Medium |
| Detection Test for Human Papillomavirus (HPV) | $188 | 58% | $79 |
Medium |
| Emergency Department Visit - Low Complexity (outpatient) | $672 | 58% | $282 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $473 | 58% | $198 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,040 | 58% | $437 |
Medium |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $149 | 58% | $63 |
Medium |
| Fetal Non-Stress Test | $910 | 58% | $382 |
Medium |
| Hernia Repair - Laparoscopic (outpatient) | $37,442 | 58% | $15,726 |
Medium |
| Mammogram (outpatient) | $866 | 58% | $364 |
Medium |
| MRI - Back (outpatient) | $4,960 | 58% | $2,083 |
Medium |
| MRI - Brain (outpatient) | $7,018 | 58% | $2,948 |
Medium |
| MRI - Knee (outpatient) | $3,945 | 58% | $1,657 |
Medium |
| MRI - Pelvis (outpatient) | $7,038 | 58% | $2,956 |
High |
| MRI - Shoulder, Elbow, or Wrist | $5,066 | 58% | $2,128 |
High |
| Myocardial Imaging (outpatient) | $8,243 | 58% | $3,462 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $502 | 58% | $211 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 1-4 Years Old | $336 | 58% | $141 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $387 | 58% | $163 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $422 | 58% | $177 |
Medium |
| Office Visit - Established Patient, High Complexity | $482 | 58% | $202 |
Medium |
| Office Visit - Established Patient, Low Complexity | $206 | 58% | $86 |
Medium |
| Office Visit - Established Patient, Moderate Complexity | $312 | 58% | $131 |
Medium |
| Pap Test | $236 | 58% | $99 |
Medium |
| Physical Therapy - Application of Hot or Cold Pack | $33 | 58% | $14 |
Medium |
| Physical Therapy - Electrical Stimulation Therapy | $79 | 58% | $33 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $195 | 58% | $82 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $342 | 58% | $144 |
Medium |
| Physical Therapy - Re-Evaluation | $229 | 58% | $96 |
Medium |
| Physical Therapy - Therapeutic Activities | $95 | 58% | $40 |
Medium |
| Physical Therapy - Therapeutic Exercises | $95 | 58% | $40 |
Medium |
| Physical Therapy - Ultrasound Therapy | $81 | 58% | $34 |
Medium |
| Psychiatric Diagnostic Evaluation | $235 | 58% | $99 |
Medium |
| Strep Test (Streptococcus, group A) | $99 | 58% | $41 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $191 | 58% | $80 |
Medium |
| Tonsillectomy with Adenoidectomy (outpatient) | $13,231 | 58% | $5,557 |
Medium |
| Ultrasound - Abdominal, Complete | $1,553 | 58% | $652 |
Medium |
| Ultrasound - Abdominal, Limited | $1,177 | 58% | $494 |
High |
| Ultrasound - Breast (outpatient) | $1,748 | 58% | $734 |
Medium |
| Ultrasound - Head and Neck | $1,384 | 58% | $581 |
Medium |
| Ultrasound - Pelvic (outpatient) | $1,282 | 58% | $538 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $1,431 | 58% | $601 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $877 | 58% | $368 |
Medium |
| Ultrasound - Transvaginal (non-maternity) | $1,326 | 58% | $557 |
Medium |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,493 | 58% | $2,727 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,427 | 58% | $3,539 |
Medium |
| Urine Capacity Measurement | $970 | 58% | $407 |
Medium |
| Urine Test - Automated with Microscope Examination | $171 | 58% | $72 |
Medium |
| Urine Test - Automated without Microscope | $191 | 58% | $80 |
Medium |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $87 | 58% | $37 |
Medium |
| Urine Test - Chlamydia | $158 | 58% | $66 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $158 | 58% | $66 |
Medium |
| Urine Test - Pregnancy | $60 | 58% | $25 |
Medium |
| X-Ray - Abdomen | $944 | 58% | $396 |
Medium |
| X-Ray - Ankle (outpatient) | $795 | 58% | $334 |
Medium |
| X-Ray - Chest (outpatient) | $865 | 58% | $363 |
Medium |
| X-Ray - Foot (outpatient) | $780 | 58% | $328 |
High |
| X-Ray - Hand | $924 | 58% | $388 |
High |
| X-Ray - Hip | $887 | 58% | $373 |
Medium |
| X-Ray - Knee (outpatient) | $894 | 58% | $376 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $978 | 58% | $411 |
Medium |
| X-Ray - Neck, Cervical Spine | $844 | 58% | $355 |
High |
| X-Ray - Pelvis | $837 | 58% | $351 |
Medium |
| X-Ray - Shoulder (outpatient) | $886 | 58% | $372 |
High |
| X-Ray - Spine (outpatient) | $1,038 | 58% | $436 |
High |
| X-Ray - Wrist (outpatient) | $779 | 58% | $327 |
High |
