| Rehabilitative Occupational and Rehabilitative Physical Therapy | $20.00 |
| Rehabilitative Speech Therapy | $20.00 |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | $250.00 Copay per Stay |
| Substance Abuse Disorder Inpatient Services | $250.00 Copay per Stay |
| Substance Abuse Disorder Outpatient Services | $10.00 |
| Transplant | $250.00 |
| Treatment for Temporomandibular Joint Disorders | $25.00 |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $15.00 |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $15.00 |
| Nutrition/Formulas | No charge |
| Nutritional Counseling | $25.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $10.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $125.00 |
| Outpatient Rehabilitation Services | $20.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | No charge |
| Radiation | No charge |
| Reconstructive Surgery | $250.00 |
| Habilitation Services | $20.00 |
| Hearing Aids | No charge |
| Home Health Care Services | No charge |
| Hormone Replacement Therapy (HRT) | $25.00 |
| Hospice Services | No charge |
| Human Leukocyte Antigen Testing | $15.00 |
| Hypodermic Syringes or Needles | $30.00 |
| Imaging (CT/PET Scans, MRIs) | $60.00 |
| Infertility Treatment | $125.00 |
| Infusion Therapy | No charge |
| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $25.00 |
| Allergy Testing | $25.00 |
| Bariatric Surgery | $250.00 |
| Bone Marrow Transplants for Treatment of Breast Cancer | $250.00 |
| Cardiac Rehabilitation | $25.00 |
| Chemotherapy | No charge |
| Chiropractic Care | $25.00 |
| Clinical Trials | $250.00 |
| Congenital Anomaly, including Cleft Lip/Palate | $250.00 |
| Contraceptive Services | No charge |
| Delivery and All Inpatient Services for Maternity Care | $250.00 |
| Diabetes Care Management | $25.00 |
| Diabetes Education | $25.00 |
| Dialysis | No charge |
| Durable Medical Equipment | No charge |
| Early Intervention Services | No charge |
| Emergency Transportation/Ambulance | No charge |
| Eye Glasses for Children | No charge |