| Ambulance Service - Mileage Rate for Ambulance Transport | $35 | 58% | $15 | 
Medium |
| Ambulance Service - Non-Emergency Transport, Advanced Life Support | $956 | 58% | $401 |
Medium |
| Arthrocentesis (outpatient) | $1,771 | 58% | $744 |
Medium |
| Arthroscopic Knee Surgery (outpatient) | $20,429 | 58% | $8,580 |
Medium |
| Arthroscopic Shoulder Surgery | $54,480 | 58% | $22,881 | 
High |
| Biopsy - Breast | $5,076 | 58% | $2,132 |
Medium |
| Biopsy - Endometrial (Uterus) | $1,653 | 58% | $694 |
Medium |
| Biopsy - Skin Lesion | $1,591 | 58% | $668 |
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 - General Health Panel | $225 | 58% | $94 |
Medium |
| Blood Test - Hepatic (Liver) Function Panel | $54 | 58% | $22 |
Medium |
| Blood Test - Pregnancy (Obstetric) Panel | $441 | 58% | $185 |
Medium |
| Blood Test - Prostate Specific Antigen (PSA) Level | $112 | 58% | $47 |
Medium |
| Blood Test - Renal (Kidney) Function Panel | $105 | 58% | $44 |
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) | $5,615 | 58% | $2,358 |
High |
| Colonoscopy - With Biopsy (outpatient) | $7,627 | 58% | $3,203 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $8,331 | 58% | $3,499 |
Medium |
| CT Scan - Abdomen and Pelvis, with Contrast | $6,836 | 58% | $2,871 |
Medium |
| CT Scan - Chest, with Contrast (outpatient) | $5,517 | 58% | $2,317 |
High |
| CT Scan - Head/Brain, without Contrast | $3,297 | 58% | $1,385 |
High |
| Cystoscopy | $3,739 | 58% | $1,570 |
Medium |
| Destruction of Lesion (outpatient) | $630 | 58% | $265 |
Medium |
| Destruction of Lesions, up to 14 | $597 | 58% | $251 |
High |
| Emergency Department Visit - Low Complexity (outpatient) | $635 | 58% | $267 |
Medium |
| Emergency Department Visit - Minor (outpatient) | $316 | 58% | $133 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $889 | 58% | $374 |
Medium |
| Fetal Non-Stress Test | $907 | 58% | $381 |
High |
| Mammogram (outpatient) | $854 | 58% | $359 |
Medium |
| MRI - Back (outpatient) | $5,123 | 58% | $2,152 |
Medium |
| MRI - Brain (outpatient) | $7,123 | 58% | $2,992 |
High |
| MRI - Knee (outpatient) | $4,153 | 58% | $1,744 |
Medium |
| MRI - Pelvis (outpatient) | $7,187 | 58% | $3,018 |
High |
| MRI - Shoulder, Elbow, or Wrist | $5,230 | 58% | $2,197 |
Medium |
| Myocardial Imaging (outpatient) | $8,736 | 58% | $3,669 |
High |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 18-39 Years Old | $420 | 58% | $176 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Evaluation and Management, New Patient, 40-64 Years Old | $489 | 58% | $206 |
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 | $368 | 58% | $154 |
Medium |
| Office Visit - Comprehensive Preventive Medicine Reevaluation and Management, 40-64 Years Old | $401 | 58% | $168 |
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 - Electrical Stimulation Therapy | $79 | 58% | $33 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $227 | 58% | $95 |
Medium |
| Physical Therapy - Moderate Complexity Evaluation | $398 | 58% | $167 |
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) | $15,191 | 58% | $6,380 |
High |
| Ultrasound - Abdominal, Complete | $1,653 | 58% | $694 |
Medium |
| Ultrasound - Abdominal, Limited | $1,119 | 58% | $470 |
High |
| Ultrasound - Breast (outpatient) | $1,447 | 58% | $608 |
High |
| Ultrasound - Head and Neck | $1,405 | 58% | $590 |
Medium |
| Ultrasound - Pelvic (outpatient) | $1,220 | 58% | $512 |
Medium |
| Ultrasound - Pregnancy (outpatient) | $1,009 | 58% | $424 |
Medium |
| Ultrasound - Pregnancy Follow-Up | $919 | 58% | $386 |
Medium |
| Ultrasound - Transvaginal (non-maternity) | $1,261 | 58% | $530 |
High |
| Upper Gastrointestinal Endoscopy - Diagnostic | $6,487 | 58% | $2,724 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $8,050 | 58% | $3,381 |
Medium |
| Urine Capacity Measurement | $944 | 58% | $396 |
Medium |
| Urine Test - Automated with Microscope Examination | $171 | 58% | $72 |
Medium |
| Urine Test - Automated without Microscope | $191 | 58% | $80 |
Medium |
| Urine Test - Bacterial Culture | $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 | $982 | 58% | $413 |
Medium |
| X-Ray - Ankle (outpatient) | $823 | 58% | $346 |
Medium |
| X-Ray - Chest (outpatient) | $899 | 58% | $377 |
Medium |
| X-Ray - Foot (outpatient) | $781 | 58% | $328 |
Medium |
| X-Ray - Hand | $900 | 58% | $378 |
Medium |
| X-Ray - Hip | $966 | 58% | $406 |
Medium |
| X-Ray - Knee (outpatient) | $893 | 58% | $375 |
Medium |
| X-Ray - Middle Back, Thoracic Spine | $1,024 | 58% | $430 |
High |
| X-Ray - Neck, Cervical Spine | $915 | 58% | $384 |
High |
| X-Ray - Pelvis | $1,147 | 58% | $482 |
Medium |
| X-Ray - Shoulder (outpatient) | $903 | 58% | $379 |
High |
| X-Ray - Spine (outpatient) | $1,152 | 58% | $484 |
High |
| X-Ray - Wrist (outpatient) | $779 | 58% | $327 |
Medium |
