| Blood Glucose Test | 82947 | $15 |
| Lipid Panel | 80061 | $17 |
| Complete Blood Count (CBC) | 85025 | $17 |
| TSH Thyroid Test | 84443 | $19 |
| HC PR ADMIN VACCINE INITIAL VFC | 90471 | $19 |
| HC PR ADMIN VACCINE INITIAL LTE 18 YEARS OLD VFC | 90460 | $19 |
| INFLUENZA VIRUS VAC SPLIT QUADRIVALENT SUSP PREF SYR 0.5ML | 90686 | $30 |
| HC PR 86580 SKIN TEST TUBERCULOSIS INTRADERMAL | 86580 | $30 |
| HC IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ # | 87591 | $40 |
| HC IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ # | 87491 | $40 |
| HC IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES # | 87624 | $44 |
| Therapeutic Injection | 96372 | $45 |
| EKG (Electrocardiogram) | 93000 | $46 |
| HC FECAL OCCULT BLD (1-3 SAMPLES) | 82270 | $47 |
| HC PR 99211 ESTAB PT VISIT - LEVEL 1 | 99211 | $92 – $94 |
| Hemoglobin A1c | 83036 | $93 |
| HC PR 92015 REFRACTIVE STATE OPHTHALMOLOGY CDM | 92015 | $106 |
| HC URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY # | 81001 | $110 |
| HC PR 11300 SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.5CM/< CDM | 11300 | $110 |
| Comprehensive Metabolic Panel | 80053 | $118 |
| HC PR 11305 SHAVE SKIN LESION 0.5 CM OR LESS SCLP NK HND FT GEN | 11305 | $121 |
| HC PR 99212 ESTAB PT VISIT - LEVEL 2 | 99212 | $130 – $135 |
| HC PR 11301 SHVG SKIN LESION TRUNK/ARM/LEG DIAM 0.6-1.0 CM CDM | 11301 | $162 |
| HC PR 99395 DOT PHYSICAL AGE 18-39 EST PT | 99395 | $164 |
| HC PR 99385 DOT PHYSICAL AGE 18-39 NEW PT | 99385 | $164 |
| Office Visit (Established Patient) | 99213 | $164 – $170 |
| HC PR 99396 DOT PHYSICAL AGE 40-64 EST PT | 99396 | $164 |
| HC PR 99386 DOT PHYSICAL AGE 40-64 NEW PT | 99386 | $164 |
| HC PR 17000 DESTRUCT PREMALG LESION FIRST LESION | 17000 | $178 |
| HC PROSTATE SPECIFIC ANTIGEN (PSA) TOTAL | 84153 | $181 |
| HC PR ED 99281 VISIT MINOR PROBLEM MAY NOT REQ PHYS/QHP CDM | 99281 | $194 |
| HC PR 99202 NEW PT VISIT - LEVEL 2 | 99202 | $196 |
| HC LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM # | 88302 | $210 |
| HC PR 17110 DESTRUCT B9 LESION 1-14 | 17110 | $218 |
| HC XR CHEST 1 VIEW | 71045 | $223 |
| HC ED REPAIR SUPERFICL WOUND(S)< 2.5CM SLP NK AX EXGEN TRNK EXTR HND FT CDM | 12001 | $229 |
| HC ED DRAINAGE OF SKIN ABSCESS SIMPLE OR SINGLE CDM | 10060 | $229 |
| HC ED EYE EXAM NEW PATIENT CDM | 92002 | $236 |
| Office Visit (Complex) | 99214 | $238 – $245 |
| HC PR 92012 EST PAT INTERMED OPHTHALMOLOGY CDM | 92012 | $240 |
| Office Visit (New Patient) | 99203 | $256 |
| Chest X-Ray (2 Views) | 71046 | $267 |
| HC PR 17111 DESTRUCTION BENIGN LESIONS 15/> CDM | 17111 | $268 |
| HC SPECIAL STAIN GROUP 1 MICROORGANISMS I&R # | 88312 | $270 |
| HC PR 11400 EXC TR-EXT B9+MARG 0.5CM/< CDM | 11400 | $273 |
| HC PR 11200 REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 CDM | 11200 | $288 |
| HC PR ED 99282 VISIT STRAIGHTFORWARD MDM CDM | 99282 | $289 |
| HC PR 11440 EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< CDM | 11440 | $346 |
| HC PR 11401 EXC TR-EXT B9+MARG 0.6-1 CM | 11401 | $346 |
| Office Visit (New, Complex) | 99204 | $360 |
| HC LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM # | 88305 | $366 |
| Knee X-Ray | 73560 | $368 |
| HC PR 20610 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US CDM | 20610 | $371 |
| HC PR 99215 ESTAB PT VISIT - LEVEL 5 | 99215 | $380 – $391 |
| HC PR 92004 OPH SVCS MEDICAL XM&EVAL COMPRE NEW PT 1/> VST | 92004 | $384 |
| HC PR 43235 ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC CDM | 43235 | $392 |
| HC PR RX HZV ZOSTER VACCINE RECOMBINANT ADJUVANTED IM 0.5 ML | 90750 | $393 |
| HC XR SHOULDER COMPLETE MIN 2 VIEWS | 73030 | $412 |
| Upper Endoscopy with Biopsy | 43239 | $441 |
| HC PR 92014 OPH SVCS MEDICAL XM&EVAL COMPRE EST PT 1/>VST CDM | 92014 | $446 |
| HC PR ED 99283 VISIT LOW MDM CDM | 99283 | $466 |
| HC PR 99205 NEW PT VISIT - LEVEL 5 | 99205 | $490 |
| HC ED EXCISION CHALAZION SINGLE CDM | 67800 | $516 |
| HC ED INCISION OF EARDRUM W/O GENERAL ANESTHESIA CDM | 69420 | $553 |
| Colonoscopy | 45378 | $590 |
| Colonoscopy with Biopsy | 45380 | $641 |
| HC PR ED 99284 VISIT MODERATE MDM CDM | 99284 | $737 |
| HC IV HYDRATION INITIAL HR | 96360 | $744 |
| HC PR 45385 COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ CDM | 45385 | $810 |
| HC PR ED 99285 VISIT HIGH MDM CDM | 99285 | $1,063 |
| Head CT Scan | 70450 | $2,352 |
| HC ED ABLATE INF TURBINATE SUPERFICIAL CDM | 30801 | $2,707 |
| HC ED CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ CDM | 27238 | $2,797 |
| Cervical Spine MRI | 72141 | $3,642 |
| Knee MRI | 73721 | $4,510 |
| Lumbar Spine MRI | 72148 | $4,583 |
| Brain MRI with Contrast | 70553 | $5,487 |
| HC ED REPAIR OF NASAL SEPTUM CDM | 30520 | $5,548 |