| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $1.00 |
| Chemotherapy | 15.00% |
| Chiropractic Care | $1.00 |
| Cosmetic Surgery | $65.00 |
| Delivery and All Inpatient Services for Maternity Care | $100.00 |
| Dental Anesthesia | 15.00% |
| Diabetes Care Management | No charge |
| Diabetes Education | No charge |
| Dialysis | 15.00% |
| Durable Medical Equipment | 15.00% |
| Emergency Transportation/Ambulance | $75.00 |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | $100.00 |
| Habilitation Services | $15.00 |
| Hearing Aids | 15.00% |
| Hearing Exams | $1.00 |
| Home Health Care Services | $5.00 |
| Hospice Services | $5.00 |
| Imaging (CT/PET Scans, MRIs) | 15.00% |
| Infertility Treatment | $65.00 |
| Infusion Therapy | 15.00% |
| Inherited Metabolic Disorder - PKU | 15.00% |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $15.00 |
| Long-Term/Custodial Nursing Home Care | $100.00 |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $1.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $100.00 |
| Outpatient Rehabilitation Services | $15.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 15.00% |
| Radiation | 15.00% |
| Reconstructive Surgery | $65.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $15.00 |
| Rehabilitative Speech Therapy | $15.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $1.00 |
| Skilled Nursing Facility | $100.00 Copay per Day |
| Substance Abuse Disorder Inpatient Services | $100.00 Copay per Day |
| Substance Abuse Disorder Outpatient Services | $1.00 |
| Transplant | $100.00 |
| Treatment for Temporomandibular Joint Disorders | $100.00 |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $20.00 |