| Ambulance Service - Emergency Transport, Advanced Life Support | $1,238 | 0% | $1,238 | 
Medium |
| Ambulance Service - Mileage Rate for Ambulance Transport | $17 | 0% | $17 |
Medium |
| Ambulance Service - Non-Emergency Transport, Basic Life Support | $680 | 0% | $680 |
Medium |
| Arthrocentesis (outpatient) | $1,237 | 0% | $1,237 |
Medium |
| Blood Test - Electrolytes Panel | $169 | 0% | $169 |
Medium |
| Blood Test - Thyroxine (Thyroid Chemical) Level, Free | $154 | 0% | $154 |
Medium |
| Blood Test - Vitamin B-12 (Cyanocobalamin) Level | $184 | 0% | $184 |
Medium |
| Blood Test - Vitamin D-3 Level | $259 | 0% | $259 |
Medium |
| Colonoscopy - Diagnostic (outpatient) | $4,800 | 0% | $4,800 |
Medium |
| Colonoscopy - With Biopsy (outpatient) | $7,098 | 0% | $7,098 |
Medium |
| Colonoscopy - With Polyp Removal (outpatient) | $6,892 | 0% | $6,892 |
Medium |
| CT Scan - Head/Brain, without Contrast | $1,665 | 0% | $1,665 |
Medium |
| Emergency Department Visit - Moderate Complexity (outpatient) | $303 | 0% | $303 |
Medium |
| MRI - Back (outpatient) | $1,683 | 0% | $1,683 | 
High |
| MRI - Brain (outpatient) | $3,358 | 0% | $3,358 |
High |
| MRI - Knee (outpatient) | $1,743 | 0% | $1,743 |
Medium |
| Physical Therapy - Low Complexity Evaluation | $228 | 0% | $228 |
Medium |
| Physical Therapy - Manual Therapy | $86 | 0% | $86 |
Medium |
| Physical Therapy - Neuromuscular Reeducation | $96 | 0% | $96 |
Medium |
| Physical Therapy - Therapeutic Exercises | $92 | 0% | $92 |
Medium |
| Physical Therapy - Ultrasound Therapy | $36 | 0% | $36 |
Medium |
| Psychiatric Diagnostic Evaluation | $261 | 0% | $261 |
Medium |
| Psychotherapy - 30 Minutes | $176 | 0% | $176 |
Medium |
| Psychotherapy - Group Session | $256 | 0% | $256 |
Medium |
| Test for Disease-Causing (Pathogenic) Organisms, Not Limited to a Specific Condition | $121 | 0% | $121 |
Medium |
| Ultrasound - Abdominal, Limited | $875 | 0% | $875 |
High |
| Ultrasound - Pregnancy Follow-Up | $843 | 0% | $843 |
Medium |
| Upper Gastrointestinal Endoscopy - With Biopsy | $7,095 | 0% | $7,095 |
Medium |
| Urine Test - Automated with Microscope Examination | $107 | 0% | $107 |
Medium |
| Urine Test - Automated without Microscope | $79 | 0% | $79 |
Medium |
| Urine Test - Chlamydia | $224 | 0% | $224 |
Medium |
| Urine Test - Gonorrhoeae (Neisseria Gonorrhoeae Bacteria) | $217 | 0% | $217 |
Medium |
| Urine Test - Pregnancy | $144 | 0% | $144 |
Medium |
| X-Ray - Chest (outpatient) | $823 | 0% | $823 |
Medium |
| X-Ray - Foot (outpatient) | $672 | 0% | $672 |
Medium |
| X-Ray - Hand | $1,073 | 0% | $1,073 |
Medium |
| X-Ray - Hip | $426 | 0% | $426 |
Medium |
| X-Ray - Shoulder (outpatient) | $818 | 0% | $818 |
High |
| X-Ray - Spine (outpatient) | $747 | 0% | $747 |
Medium |
| X-Ray - Wrist (outpatient) | $525 | 0% | $525 |
Medium |
