| HC ED SEXUAL ASSAULT EXAM CDM | 99284 | $0 |
| HC PR ADMIN VACCINE HEPATITIS B CDM | 90471 | $2 |
| HC PR RX HZV ZOSTER VACCINE RECOMBINANT ADJUVANTED IM 0.5 ML | 90750 | $4 |
| HC BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER CDM | 82270 | $8 – $24 |
| HC TB INTRADERMAL TEST - PPD | 86580 | $8 |
| Therapeutic Injection | 96372 | $11 |
| HC PR 99211 OFFICE OUTPATIENT VISIT RHC | 99211 | $19 |
| Blood Glucose Test | 82947 | $21 |
| HC CHOLESTEROL | 82465 | $24 |
| HC PR 11305 SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/OR LESS RHC | 11305 | $25 |
| EKG (Electrocardiogram) | 93000 | $26 |
| HC PR RX INFLUENZA QUADRIVALENT (IIV4) PF IM 0.5 ML | 90686 | $29 |
| HC URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY LAB | 81001 | $33 |
| HC PR 11200 REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 RHC | 11200 | $36 |
| HC PR 96360 IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR RHC | 96360 | $46 |
| Complete Blood Count (CBC) | 85025 | $47 |
| Hemoglobin A1c | 83036 | $52 |
| HC PR 99212 OFFICE OUTPATIENT VISIT RHC | 99212 | $53 |
| HC PR 20610 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US RHC | 20610 | $63 |
| Office Visit (Established Patient) | 99213 | $70 |
| HC PR 99202 OFFICE OUTPATIENT NEW RHC | 99202 | $71 |
| HC PR 11300 SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.5CM/OR LESS RHC | 11300 | $73 |
| HC CHLAMYDIA TRACHOMATIS PCR | 87491 | $81 |
| HC IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ | 87591 | $81 |
| Office Visit (New Patient) | 99203 | $87 |
| Office Visit (Complex) | 99214 | $87 |
| HC PR 17110 DESTRUCTION BENIGN LESIONS UP TO 14 RHC | 17110 | $90 |
| TSH Thyroid Test | 84443 | $90 |
| HC PR 12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/OR LESS RHC | 12001 | $95 |
| HC PR 11301 SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM RHC | 11301 | $95 |
| HC PR 99395 PREVENTIVE VISIT EST 18-39 RHC | 99395 | $97 |
| HC PR 10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE RHC | 10060 | $97 |
| HC ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL CDM | 84153 | $99 |
| HC PR11400 EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/OR LESS RHC | 11400 | $101 |
| HC PR 99396 PREVENTIVE VISIT EST 40-64 RHC | 99396 | $103 |
| HC PR 99385 INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS RHC | 99385 | $103 |
| HC HIV-1/HIV-2 SINGLE ASSAY | 86703 | $105 |
| HC PR 17111 DESTRUCTION BENIGN LESIONS 15/> RHC | 17111 | $107 |
| Comprehensive Metabolic Panel | 80053 | $110 |
| HC PR 17000 DESTRUCTION PREMALIGNANT LESION 1ST RHC | 17000 | $112 |
| HC PR 11440 EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/OR LESS RHC | 11440 | $113 |
| Office Visit (New, Complex) | 99204 | $119 |
| HC PR 99215 OFFICE OUTPATIENT VISIT RHC | 99215 | $119 |
| HC PR 99386 PREVENTIVE VISIT NEW 40-64 RHC | 99386 | $121 |
| HC PR 11401 EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM RHC | 11401 | $126 |
| HC LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY LAB | 88300 | $126 |
| HC LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88302 | $126 |
| Lipid Panel | 80061 | $139 |
| HC ED EYE EXAM NEW PATIENT CDM | 92002 | $140 |
| Knee X-Ray | 73560 | $147 |
| HC XR SHOULDER COMPLETE MIN 2 VIEWS | 73030 | $147 |
| HC PR 99205 OFFICE OUTPATIENT NEW RHC | 99205 | $147 |
| HC ED FAC E&M VISIT LEVEL 1 CDM | 99281 | $151 |
| Chest X-Ray (2 Views) | 71046 | $160 |
| HC XR CHEST 1 VIEW | 71045 | $160 |
| Mammogram (Screening) | 77067 | $166 |
| DEXA Bone Density Scan | 77080 | $198 |
| HC MICROSLIDE CONSULTATION W/ SLIDE PREP | 88323 | $255 |
| HC LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88305 | $255 |
| HC SPECIAL STAIN GROUP 1 MICROORGANISMS I&R LAB | 88312 | $255 |
| HC LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88304 | $255 |
| HC ED FAC E&M VISIT LEVEL 2 CDM | 99282 | $273 |
| HC ED INCISION OF EARDRUM W/O GENERAL ANESTHESIA CDM | 69420 | $276 |
| HC ED EXCISION CHALAZION SINGLE CDM | 67800 | $306 |
| HC ED FAC E&M VISIT LEVEL 3 CDM | 99283 | $481 |
| Lumbar Spine MRI | 72148 | $677 |
| Head CT Scan | 70450 | $748 |
| HC PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC LAB | 88331 | $764 |
| Echocardiogram | 93306 | $844 |
| Upper Endoscopy with Biopsy | 43239 | $955 |
| HC ED ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC CDM | 43235 | $955 |
| Colonoscopy | 45378 | $961 |
| Knee MRI | 73721 | $1,013 |
| HC ED FAC E&M VISIT LEVEL 5 CDM | 99285 | $1,116 |
| HC ED CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ CDM | 27238 | $1,135 |
| Cervical Spine MRI | 72141 | $1,259 |
| HC LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88307 | $1,493 |
| HC ED ABLATE INF TURBINATE SUPERFICIAL CDM | 30801 | $1,846 |
| Brain MRI with Contrast | 70553 | $2,056 |
| HC LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88309 | $3,362 |
| HC ED REPAIR OF NASAL SEPTUM CDM | 30520 | $3,784 |