| Ambulance Service - Mileage Rate for Ambulance Transport | $37 | 58% | $15 |
| Ambulance Service - Non-Emergency Transport, Advanced Life Support | $956 | 58% | $401 |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $665 | 58% | $279 |
| Arthrocentesis (outpatient) | $2,144 | 58% | $900 |
| Arthroscopic Knee Surgery (outpatient) | $20,348 | 58% | $8,546 |
| Bacterial Culture - Aerobic Isolates | $101 | 58% | $42 |
| Bacterial Culture - Swab | $187 | 58% | $78 |
| Biopsy - Breast | $4,437 | 58% | $1,864 |
| Biopsy - Endometrial (Uterus) | $1,699 | 58% | $714 |
| Biopsy - Punch Biopsy of Skin | $1,935 | 58% | $813 |
| Biopsy - Tangential Biopsy of Skin | $1,483 | 58% | $623 |
| Blood Test - Basic Metabolic Panel | $48 | 58% | $20 |
| Blood Test - Blood Glucose Control (Hemoglobin A1C) | $98 | 58% | $41 |
| Blood Test - Cholesterol Test, Lipid Panel | $95 | 58% | $40 |
| Blood Test - Clotting Time | $50 | 58% | $21 |
| Blood Test - Coagulation Assessment | $51 | 58% | $22 |
| Blood Test - Complete Blood Cell Count (Hemoglobin) | $67 | 58% | $28 |
| Blood Test - Complete Blood Cell Count and Automated WBC | $70 | 58% | $30 |
| Blood Test - Comprehensive Metabolic Panel | $60 | 58% | $25 |
| Blood Test - Electrolytes Panel | $37 | 58% | $15 |
| Blood Test - Ferritin (Blood Protein) Level | $78 | 58% | $33 |
| Blood Test - Folic Acid Level | $101 | 58% | $42 |
| Blood Test - General Health Panel | $225 | 58% | $94 |
| Blood Test - Hepatic (Liver) Function Panel | $54 | 58% | $22 |
| Blood Test - Hepatitis C Antibody Level | $216 | 58% | $91 |
| Blood Test - Iron Level | $28 | 58% | $12 |
| Blood Test - LDL Cholesterol Level | $66 | 58% | $28 |
| Blood Test - Lipase (fat enzyme) Level | $30 | 58% | $13 |
| Blood Test - Prostate Specific Antigen (PSA) Level | $112 | 58% | $47 |
| Blood Test - Renal (Kidney) Function Panel | $81 | 58% | $34 |
| Blood Test - Thyroid Stimulating Hormone (TSH) Level | $95 | 58% | $40 |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $111 | 58% | $47 |
| Blood Test - Triiodothyronine (T3) Thyroid Hormone Measurement | $85 | 58% | $36 |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $97 | 58% | $41 |
| Blood Test - Vitamin D-3 Level | $186 | 58% | $78 |
| Bone Density Scan (outpatient) | $781 | 58% | $328 |
| Colonoscopy - Diagnostic (outpatient) | $5,960 | 58% | $2,503 |
| Colonoscopy - With Biopsy (outpatient) | $8,150 | 58% | $3,423 |
| Colonoscopy - With Polyp Removal (outpatient) | $8,822 | 58% | $3,705 |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,942 | 58% | $2,915 |
| CT Scan - Chest, with Contrast (outpatient) | $5,305 | 58% | $2,228 |
| CT Scan - Head/Brain, without Contrast | $3,117 | 58% | $1,309 |
| Cystoscopy | $3,537 | 58% | $1,486 |
| Destruction of Lesion (outpatient) | $665 | 58% | $279 |
| Destruction of Lesions, up to 14 | $675 | 58% | $284 |
| Detection test for Human Papillomavirus (HPV) | $188 | 58% | $79 |
| Emergency Department Visit - Low Complexity (outpatient) | $672 | 58% | $282 |
| Emergency Department Visit - Minor (outpatient) | $473 | 58% | $198 |
| Emergency Department Visit - Moderate Complexity (outpatient) | $1,040 | 58% | $437 |
| Evaluation of Antimicrobial Drug (antibiotic, antifungal, antiviral) | $149 | 58% | $63 |
| Fetal Non-Stress Test | $960 | 58% | $403 |
| Hernia Repair - Laparoscopic (outpatient) | $35,565 | 58% | $14,937 |
| Lab Test - Detection test for Hepatitis B Surface Antigen | $190 | 58% | $80 |
| Lab Test - Detection test for HIV-1 and HIV-2 | $188 | 58% | $79 |
| Lab Test - Smear for Microorganism | $109 | 58% | $46 |
| Mammogram (outpatient) | $920 | 58% | $386 |
| MRI - Back (outpatient) | $4,960 | 58% | $2,083 |
| MRI - Brain (outpatient) | $6,902 | 58% | $2,899 |
| MRI - Knee (outpatient) | $3,945 | 58% | $1,657 |
| MRI - Pelvis (outpatient) | $7,053 | 58% | $2,962 |
| MRI - Shoulder, Elbow, or Wrist | $5,066 | 58% | $2,128 |
| Myocardial Imaging (outpatient) | $8,924 | 58% | $3,748 |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $516 | 58% | $217 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 18-39 Years Old | $387 | 58% | $163 |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $422 | 58% | $177 |
| Office Visit - Established Patient, Moderate Complexity | $357 | 58% | $150 |
| Pap Test | $236 | 58% | $99 |
| Physical Therapy - Application of Hot or Cold Pack | $33 | 58% | $14 |
| Physical Therapy - Electrical Stimulation Therapy | $79 | 58% | $33 |
| Physical Therapy - High Complexity Evaluation | $590 | 58% | $248 |
| Physical Therapy - Low Complexity Evaluation | $195 | 58% | $82 |
| Physical Therapy - Moderate Complexity Evaluation | $342 | 58% | $144 |
| Physical Therapy - Therapeutic Activities | $95 | 58% | $40 |
| Physical Therapy - Therapeutic Exercises | $95 | 58% | $40 |
| Physical Therapy - Ultrasound Therapy | $81 | 58% | $34 |
| Strep Test (Streptococcus, group A) | $99 | 58% | $41 |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $191 | 58% | $80 |
| Tonsillectomy with Adenoidectomy (outpatient) | $13,270 | 58% | $5,574 |
| Ultrasound - Abdominal, Complete | $1,556 | 58% | $654 |
| Ultrasound - Abdominal, Limited | $1,326 | 58% | $557 |
| Ultrasound - Breast (outpatient) | $1,748 | 58% | $734 |
| Ultrasound - Head and Neck | $1,546 | 58% | $649 |
| Ultrasound - Pelvic (outpatient) | $1,329 | 58% | $558 |
| Ultrasound - Pregnancy (outpatient) | $1,504 | 58% | $632 |
| Ultrasound - Pregnancy Follow-Up | $927 | 58% | $389 |
| Ultrasound - Transvaginal (non-maternity) | $1,326 | 58% | $557 |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,782 | 58% | $2,849 |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,567 | 58% | $3,598 |
| Urine Capacity Measurement | $932 | 58% | $391 |
| Urine Test - Automated with Microscope Examination | $171 | 58% | $72 |
| Urine Test - Automated without Microscope | $191 | 58% | $80 |
| Urine Test - Bacterial Culture, Quantitative Colony Count | $87 | 58% | $37 |
| Urine Test - Chlamydia | $158 | 58% | $66 |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $158 | 58% | $66 |
| Urine Test - Microalbumin (Protein) Level | $69 | 58% | $29 |
| Urine Test - Pregnancy | $60 | 58% | $25 |
| Urine Test - Urinalysis, Manual Test | $55 | 58% | $23 |
| Vaccine - Tetanus, Diptheria Toxoids, and Acellular Pertussis (Whooping Cough) for Injection into Muscle | $141 | 58% | $59 |
| X-Ray - Abdomen | $1,038 | 58% | $436 |
| X-Ray - Ankle (outpatient) | $666 | 58% | $280 |
| X-Ray - Chest (outpatient) | $870 | 58% | $366 |
| X-Ray - Foot (outpatient) | $769 | 58% | $323 |
| X-Ray - Hand | $965 | 58% | $405 |
| X-Ray - Hip | $887 | 58% | $373 |
| X-Ray - Knee (outpatient) | $929 | 58% | $390 |
| X-Ray - Middle Back, Thoracic Spine | $950 | 58% | $399 |
| X-Ray - Neck, Cervical Spine | $844 | 58% | $355 |
| X-Ray - Pelvis | $729 | 58% | $306 |
| X-Ray - Shoulder (outpatient) | $863 | 58% | $363 |
| X-Ray - Spine (outpatient) | $1,036 | 58% | $435 |
| X-Ray - Wrist (outpatient) | $834 | 58% | $350 |
