| Ambulance Service - Mileage Rate for Ambulance Transport | $37 | N/A | $15 |
| Ambulance Service - Non-Emergency Transport, Advanced Life Support | $956 | N/A | $382 |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $665 | N/A | $266 |
| Arthrocentesis (outpatient) | $2,144 | N/A | $858 |
| Arthroscopic Knee Surgery (outpatient) | $22,212 | N/A | $8,885 |
| Arthroscopic Shoulder Surgery | $67,727 | N/A | $27,091 |
| Bacterial Culture - Aerobic Isolates | $105 | N/A | $42 |
| Bacterial Culture - Swab | $194 | N/A | $78 |
| Biopsy - Breast | $4,437 | N/A | $1,775 |
| Biopsy - Endometrial (Uterus) | $1,724 | N/A | $690 |
| Biopsy - Punch Biopsy of Skin | $1,935 | N/A | $774 |
| Biopsy - Tangential Biopsy of Skin | $1,490 | N/A | $596 |
| Blood Test - Basic Metabolic Panel | $50 | N/A | $20 |
| Blood Test - Blood Glucose (Sugar) Level | $24 | N/A | $10 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $102 | N/A | $41 |
| Blood Test - Blood Typing (ABO) | $82 | N/A | $33 |
| Blood Test - Blood Typing (Rh (D)) | $113 | N/A | $45 |
| Blood Test - C-reactive Protein (CRP) Level | $170 | N/A | $68 |
| Blood Test - Cholesterol Test, Lipid Panel | $99 | N/A | $39 |
| Blood Test - Clotting Time | $53 | N/A | $21 |
| Blood Test - Coagulation Assessment | $54 | N/A | $21 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $70 | N/A | $28 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $74 | N/A | $29 |
| Blood Test - Comprehensive Metabolic Panel | $62 | N/A | $25 |
| Blood Test - Coronavirus (COVID-19) Antibody Level | $57 | N/A | $23 |
| Blood Test - Creatinine Level | $29 | N/A | $12 |
| Blood Test - Electrolytes Panel | $38 | N/A | $15 |
| Blood Test - Ferritin (Blood Protein) Level | $81 | N/A | $32 |
| Blood Test - Folic Acid Level | $105 | N/A | $42 |
| Blood Test - General Health Panel | $234 | N/A | $94 |
| Blood Test - Hepatic (Liver) Function Panel | $56 | N/A | $22 |
| Blood Test - Hepatitis B Surface Antibody Level | $195 | N/A | $78 |
| Blood Test - Hepatitis C Antibody Level | $225 | N/A | $90 |
| Blood Test - Iron Binding Capacity | $32 | N/A | $13 |
| Blood Test - Iron Level | $29 | N/A | $12 |
| Blood Test - LDL Cholesterol Level | $69 | N/A | $28 |
| Blood Test - Lead Level | $38 | N/A | $15 |
| Blood Test - Lipase (fat enzyme) Level | $32 | N/A | $13 |
| Blood Test - Magnesium Level | $39 | N/A | $16 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $117 | N/A | $47 |
| Blood Test - Renal (Kidney) Function Panel | $81 | N/A | $32 |
| Blood Test - Thyroglobulin (Thyroid Protein) Antibody Level | $251 | N/A | $100 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $99 | N/A | $39 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $116 | N/A | $46 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $88 | N/A | $35 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $101 | N/A | $40 |
| Blood Test - Vitamin D-3 Level | $120 | N/A | $48 |
| Bone Density Scan (outpatient) | $999 | N/A | $399 |
| Colonoscopy - Diagnostic (outpatient) | $5,970 | N/A | $2,388 |
| Colonoscopy - With Biopsy (outpatient) | $8,487 | N/A | $3,395 |
| Colonoscopy - With Polyp Removal (outpatient) | $9,044 | N/A | $3,618 |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,951 | N/A | $2,780 |
| CT Scan - Chest, with Contrast (outpatient) | $5,329 | N/A | $2,132 |
| CT Scan - Head/Brain, without Contrast | $3,145 | N/A | $1,258 |
| Cystoscopy | $3,624 | N/A | $1,449 |
| Destruction of Lesion (outpatient) | $632 | N/A | $253 |
| Destruction of Lesions, up to 14 | $681 | N/A | $273 |
| Emergency Department Visit - Low Complexity (outpatient) | $719 | N/A | $288 |
| Emergency Department Visit - Minor (outpatient) | $489 | N/A | $196 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,112 | N/A | $445 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $155 | N/A | $62 |
| Fetal Non-Stress Test | $968 | N/A | $387 |
| Gall Bladder Surgery (outpatient) | $34,186 | N/A | $13,674 |
| Hernia Repair - Laparoscopic (outpatient) | $34,514 | N/A | $13,805 |
| Hydration Infusion | $238 | N/A | $95 |
| Lab Test - Creatinine Level | $29 | N/A | $12 |
| Lab Test - Detection for Strep (Streptococcus, group A) | $103 | N/A | $41 |
| Lab Test - Detection test for Coronavirus (COVID-19) | $107 | N/A | $43 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $197 | N/A | $79 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $195 | N/A | $78 |
| Lab Test - Detection test for Human Papillomavirus (HPV) | $195 | N/A | $78 |
| Lab Test - Smear for Microorganism | $113 | N/A | $45 |
| Mammogram (outpatient) | $920 | N/A | $368 |
| MRI - Back (outpatient) | $5,000 | N/A | $2,000 |
| MRI - Brain (outpatient) | $7,051 | N/A | $2,820 |
| MRI - Knee (outpatient) | $3,945 | N/A | $1,578 |
| MRI - Pelvis (outpatient) | $7,097 | N/A | $2,839 |
| MRI - Shoulder, Elbow, or Wrist | $5,107 | N/A | $2,043 |
| Myocardial Imaging (outpatient) | $9,105 | N/A | $3,642 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $387 | N/A | $155 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $439 | N/A | $176 |
| Office Visit - Established Patient, High Complexity | $501 | N/A | $200 |
| Office Visit - Established Patient, Moderate Complexity | $357 | N/A | $143 |
| Pap Test, automated screening and manual rescreening | $246 | N/A | $98 |
| Pap Test, manual screening | $189 | N/A | $76 |
| Physical Therapy - Application of Hot or Cold Pack | $33 | 
Below Average
State Average: 3 | $13 |
| Physical Therapy - Electrical Stimulation Therapy | $79 |
Below Average
State Average: 3 | $32 |
| Physical Therapy - Low Complexity Evaluation | $195 | 
Near Average
State Average: 1 | $78 |
| Physical Therapy - Moderate Complexity Evaluation | $342 |
Near Average
State Average: 1 | $137 |
| Physical Therapy - Therapeutic Activities | $95 |
Below Average
State Average: 3 | $38 |
| Physical Therapy - Therapeutic Exercises | $95 |
Below Average
State Average: 4 | $38 |
| Physical Therapy - Ultrasound Therapy | $81 |
Below Average
State Average: 3 | $32 |
| Physical Therapy - Walking Training, 15 minutes | $168 | 
Above Average
State Average: 1 | $67 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $191 | N/A | $76 |
| Tonsillectomy with Adenoidectomy (outpatient) | $13,780 | N/A | $5,512 |
| Ultrasound - Abdominal, Complete | $1,725 | N/A | $690 |
| Ultrasound - Abdominal, Limited | $1,400 | N/A | $560 |
| Ultrasound - Breast (outpatient) | $1,744 | N/A | $698 |
| Ultrasound - Head and Neck | $1,512 | N/A | $605 |
| Ultrasound - Pelvic (outpatient) | $1,329 | N/A | $532 |
| Ultrasound - Pregnancy (outpatient) | $990 | N/A | $396 |
| Ultrasound - Pregnancy Follow-Up | $927 | N/A | $371 |
| Ultrasound - Transvaginal (non-maternity) | $1,403 | N/A | $561 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $7,182 | N/A | $2,873 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,810 | N/A | $3,524 |
| Urine Capacity Measurement | $1,000 | N/A | $400 |
| Urine Test - Automated with Microscope Examination | $179 | N/A | $71 |
| Urine Test - Automated without Microscope | $198 | N/A | $79 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $90 | N/A | $36 |
| Urine Test - Chlamydia | $164 | N/A | $66 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $164 | N/A | $66 |
| Urine Test - Microalbumin (Protein) Level | $72 | N/A | $29 |
| Urine Test - Pregnancy | $62 | N/A | $25 |
| Urine Test - Urinalysis, Manual Test | $57 | N/A | $23 |
| Vaccine - Influenza for Injection into Muscle | $62 | N/A | $25 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $144 | N/A | $57 |
| X-Ray - Abdomen | $1,093 | N/A | $437 |
| X-Ray - Ankle (outpatient) | $622 | N/A | $249 |
| X-Ray - Chest (outpatient) | $883 | N/A | $353 |
| X-Ray - Foot (outpatient) | $769 | N/A | $307 |
| X-Ray - Hand | $974 | N/A | $390 |
| X-Ray - Hip | $906 | N/A | $362 |
| X-Ray - Knee (outpatient) | $1,056 | N/A | $423 |
| X-Ray - Middle Back, Thoracic Spine | $1,226 | N/A | $491 |
| X-Ray - Neck, Cervical Spine | $844 | N/A | $338 |
| X-Ray - Pelvis | $736 | N/A | $294 |
| X-Ray - Shoulder (outpatient) | $863 | N/A | $345 |
| X-Ray - Spine (outpatient) | $1,039 | N/A | $416 |
| X-Ray - Wrist (outpatient) | $910 | N/A | $364 |
