| CHG URINALYSIS, AUTO, W/SCOPE | 81001 | $8 |
| BLOOD OCCULT,BY PEROXID,FECES,SINGLE, COLORECTAL SCREEN | 82270 | $10 |
| Blood Glucose Test | 82947 | $10 |
| ASSAY, BLD/SERUM CHOLESTEROL | 82465 | $11 |
| CHG SURG PATH,GROSS,LEVEL I (26) | 88300 | $11 |
| CHG RADIOLOGIC EXAM CHEST SINGLE VIEW (26) | 71045 | $17 |
| CHG TB INTRADERMAL TEST | 86580 | $18 |
| CHG SURG PATH,LEVEL II (26) | 88302 | $19 |
| Complete Blood Count (CBC) | 85025 | $20 |
| Chest X-Ray (2 Views) | 71046 | $20 |
| PR IIV4 VACC PRESRV FREE 0.5 ML DOS FOR IM USE | 90686 | $22 |
| Knee X-Ray | 73560 | $22 |
| DEXA Bone Density Scan | 77080 | $24 |
| Hemoglobin A1c | 83036 | $25 |
| CHG X-RAY SHOULDER 2+ VW (26) | 73030 | $25 |
| PR DEXA,BONE DENSITY,APPENDICULR SKELTN (26) | 77081 | $26 |
| Comprehensive Metabolic Panel | 80053 | $27 |
| PR ANTIBODY HIV-1&HIV-2 SINGLE RESULT | 86703 | $28 |
| CHG SURG PATH,LEVEL III (26) | 88304 | $29 |
| PR COMPUTERIZED OPHTHALMIC IMAGING RETINA (TC) | 92134 | $30 |
| Lipid Panel | 80061 | $34 |
| PR COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI W/I&R (TC) | 92025 | $34 |
| SOCIAL WORKER VISIT 99211 | 99211 | $38 |
| EKG (Electrocardiogram) | 93000 | $38 |
| PR EMERGENCY DEPARTMENT VISIT MAY NOT REQ PHYS/QHP | 99281 | $41 |
| TSH Thyroid Test | 84443 | $42 |
| HC ED LEVEL 2 INIT ASSESS | 99282 | $44 |
| HC ED LEVEL 4 INIT ASSESS | 99284 | $44 |
| Therapeutic Injection | 96372 | $44 |
| HC ED LEVEL 3 INIT ASSESS | 99283 | $44 |
| HC ED LEVEL 5 INIT ASSESS | 99285 | $44 |
| PR IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID | 90471 | $46 |
| CHG PROSTATE SPECIFIC ANTIGEN,TOTAL | 84153 | $46 |
| PR IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX | 90460 | $46 |
| PR EXTENDED VISUAL FIELD XM UNI/BI I&R (26) | 92083 | $59 |
| PR SPECIAL STAIN GROUP 1 MICROORGANISMS I&R (26) | 88312 | $60 |
| HC HPV HIGH-RISK TYPES | 87624 | $67 |
| HC CHLAMYDIA T, AMPLIF NA PROBE | 87491 | $67 |
| HC NEISSERIA, AMPLIF NA PROBE | 87591 | $67 |
| Mammogram (Screening) | 77067 | $67 |
| CHG PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1ST SPEC (TC) | 88331 | $72 |
| CHG SURG PATH,LEVEL IV (TC) | 88305 | $72 |
| PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN | 99212 | $83 |
| HC REF CONSULT W SLIDE PREP | 88323 | $97 |
| Head CT Scan | 70450 | $101 |
| PR IV INFUSION, HYDRATION, 31-60 MIN | 96360 | $102 |
| PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES | 99202 | $134 |
| PR DRAIN/INJECT LARGE JOINT/BURSA | 20610 | $153 |
| Office Visit (Established Patient) | 99213 | $161 |
| Knee MRI | 73721 | $161 |
| PR DESTRUC PREMALIGNANT, FIRST LESION | 17000 | $161 |
| PR PSYCHOTHERAPY W/PATIENT 30 MINUTES | 90832 | $168 |
| Echocardiogram | 93306 | $172 |
| PR OPH SCVS MEDICAL XM&EVAL INTERMEDIATE NEW PT | 92002 | $174 |
| Cervical Spine MRI | 72141 | $175 |
| Lumbar Spine MRI | 72148 | $175 |
| PR OPH SVCS MEDICAL XM&EVAL INTERMEDIATE EST PT | 92012 | $183 |
| Office Visit (New Patient) | 99203 | $190 |
| Office Visit (Complex) | 99214 | $192 |
| PR PSYCHOTHERAPY W/PATIENT 45 MINUTES | 90834 | $210 |
| PR HZV ZOSTER VACC RECOMBINANT ADJUVANTED IM NJX | 90750 | $212 |
| PR PREVENTIVE VISIT,EST,18-39 | 99395 | $213 |
| PR RMVL SKIN TAGS MLT FIBRQ TAGS ANY UP TO&INC 15 | 11200 | $218 |
| PR REPR SUPERF WND BODY <2.5CM | 12001 | $221 |
| PR POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND (26) | 95808 | $222 |
| PR PREVENTIVE VISIT,EST,40-64 | 99396 | $226 |
| HC SHAVE LES S/N/H/F/G 0.5 CM/< | 11305 | $231 |
| HC I&D ABSC SMPL OR SGL | 10060 | $232 |
| PR PREVENTIVE VISIT,NEW,18-39 | 99385 | $235 |
| PR SHAV SKIN LES <5MM TRUNK,ARM,LEG | 11300 | $245 |
| PR OPH SVCS MEDICAL XM&EVAL COMPRE EST PT 1/>VST | 92014 | $261 |
| PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN | 99215 | $266 |
| Brain MRI with Contrast | 70553 | $270 |
| PR PREVENTIVE VISIT,NEW,40-64 | 99386 | $273 |
| PR DESTRUCTION BENIGN LESIONS UP TO 14 | 17110 | $273 |
| CHG SURG PATH,LEVEL V (26) | 88307 | $280 |
| Office Visit (New, Complex) | 99204 | $290 |
| PR POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND (26) | 95810 | $296 |
| PR SHAV SKIN LES 6-10MM TRUNK,ARM,LEG | 11301 | $298 |
| PR EXC SKIN BENIG <5MM TRUNK,ARM,LEG | 11400 | $307 |
| PR OPH SVCS MEDICAL XM&EVAL COMPRE NEW PT 1/> VST | 92004 | $312 |
| Psychotherapy (60 min) | 90837 | $314 |
| PR EXCIS CHALAZION,SINGLE | 67800 | $318 |
| DESTRUCTION BENIGN LESIONS 15 OR MORE | 17111 | $322 |
| PR PSYCHIATRIC DIAGNOSTIC EVALUATION | 90791 | $324 |
| PR EXC SKIN BENIG <5MM FACE,FACIAL | 11440 | $343 |
| PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES | 99205 | $367 |
| PR BIOPSY OF BREAST, NEEDLE CORE | 19100 | $373 |
| PR EXC SKIN BENIG 0.6-1CM TRUNK,ARM,LEG | 11401 | $375 |
| PR CREATE EARDRUM OPENING,GEN ANESTH | 69436 | $387 |
| CHG SURG PATH,LEVEL VI (26) | 88309 | $432 |
| PR INCISION EARDRUM,ASPIR | 69420 | $457 |
| PR EXCIS CHALAZION,MULT,BOTH LIDS | 67805 | $501 |
| PR CAUTER TURBINATE MUCOSA,SUPERFICIAL | 30801 | $530 |
| Epidural Steroid Injection | 64483 | $582 |
| PR TRABECULOPLASTY BY LASER SURGERY | 65855 | $612 |
| PR BIOPSY OF PROSTATE,NEEDLE/PUNCH | 55700 | $614 |
| PR NASAL/SINUS NDSC SURG W/BX POLYPC/DBRDMT SPX | 31237 | $622 |
| PR REMOVAL OF TONSILS,12+ Y/O | 42826 | $622 |
| REMOVAL OF TONSILS,<12 Y/O | 42825 | $650 |
| PR ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC | 43235 | $687 |
| REMOVE TONSILS/ADENOIDS,<12 Y/O | 42820 | $715 |
| PR REMOVE TONSILS/ADENOIDS,12+ Y/O | 42821 | $746 |
| PR EXCISION TURBINATE,SUBMUCOUS | 30140 | $785 |
| Colonoscopy | 45378 | $814 |
| Upper Endoscopy with Biopsy | 43239 | $914 |
| PR EXCISION TURBINATE | 30130 | $971 |
| Colonoscopy with Biopsy | 45380 | $1,047 |
| PR COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ | 45385 | $1,097 |
| PR CLOSED RX INTER/SUBTROCH FEMUR FX | 27238 | $1,140 |
| PR ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG | 29881 | $1,330 |
| PR LAP,APPENDECTOMY | 44970 | $1,473 |
| PR APPENDECTOMY | 44950 | $1,577 |
| PR REPAIR OF NASAL SEPTUM | 30520 | $1,590 |
| PR MASTECTOMY, PARTIAL | 19301 | $1,604 |
| Laparoscopic Cholecystectomy | 47562 | $1,614 |
| PR TRANSURETHRAL ELEC-SURG PROSTATECTOM | 52601 | $1,842 |
| PR VAGINAL HYSTERECTOMY,UTERUS 250 GMS/< | 58260 | $2,087 |
| PR APPENDECTOMY,RUPT APPENDX+ABSCESS | 44960 | $2,150 |
| PR MASTECTOMY,PARTIAL, WITH AXILLARY LYMPHADENECTOMY | 19302 | $2,203 |
| PR LAPAROSCOPY W TOT HYSTERECTUTERUS <=250 GRAM W TUBE/OVARY | 58571 | $2,235 |
| PR MASTECTOMY, SIMPLE, COMPLETE | 19303 | $2,342 |
| PR KNEE SCOPE,AID ANT CRUCIATE REPAIR | 29888 | $2,416 |
| PR LAP,VAG HYST,UTERUS 250GMS/<,SALP-OOPH | 58552 | $2,458 |
| PR TOTAL ABDOM HYSTERECTOMY | 58150 | $2,521 |
| Shoulder Arthroscopy | 29827 | $2,636 |
| PR FEMORAL FX, OPEN TX | 27236 | $2,942 |
| PR MASTECTOMY, MODIFIED RADICAL | 19307 | $2,943 |
| Total Knee Replacement | 27447 | $3,334 |
| Total Hip Replacement | 27130 | $3,338 |
| PR REVISE KNEE JOINT REPLACE,1 PART | 27486 | $3,464 |
| PR LAP,PROSTATECTOMY,RADICAL,W/NERVE SPARE | 55866 | $3,648 |
| PR REVISE KNEE JOINT REPLACE,ALL PARTS | 27487 | $4,332 |