| ADMINISTRATION OF FIRST VACCINE OR TOXOID COMPONENT WITH COUNSELING (18 YEARS OR YOUNGER) | 90460 | $18 |
| X-RAY OF CHEST; 1 VIEW | 71045 | $25 |
| Hemoglobin A1c | 83036 | $28 |
| OCCULT BLOOD FECES | 82270 | $29 |
| Chest X-Ray (2 Views) | 71046 | $31 |
| Blood Glucose Test | 82947 | $35 |
| Therapeutic Injection | 96372 | $38 |
| Knee X-Ray | 73560 | $39 |
| ASSAY BLD/SERUM CHOLESTEROL | 82465 | $42 |
| MANUAL URINALYSIS TEST WITH EXAMINATION USING MICROSCOPE; AUTOMATED | 81001 | $42 |
| EMERGENCY DEPARTMENT VISIT FOR PROBLEM OF MILD SEVERITY | 99281 | $44 |
| X-RAY OF SHOULDER; MINIMUM OF 2 VIEWS | 73030 | $44 |
| TB INTRADERMAL TEST | 86580 | $47 |
| DEXA Bone Density Scan | 77080 | $47 |
| PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE; LIMITED EXAMINATION | 88300 | $50 |
| Complete Blood Count (CBC) | 85025 | $51 |
| DESTRUCTION OF PRECANCER SKIN GROWTH; 1 GROWTH | 17000 | $66 |
| Lipid Panel | 80061 | $69 |
| ASPIRATION AND/OR INJECTION OF FLUID FROM LARGE JOINT | 20610 | $69 |
| INCISION; ASPIRATION; AND/OR INFLATION OF EARDRUM | 69420 | $75 |
| ESTABLISHED PATIENT OFFICE OR OTHER OUTPATIENT VISIT; 10-19 MINUTES | 99212 | $76 |
| ANALYSIS FOR ANTIBODY TO HIV-1 AND HIV-2 VIRUS | 86703 | $85 |
| EMERGENCY DEPARTMENT VISIT FOR PROBLEM OF MILD TO MODERATE SEVERITY | 99282 | $86 |
| PSA (PROSTATE SPECIFIC ANTIGEN) MEASUREMENT; TOTAL | 84153 | $86 |
| DESTRUCTION OF SKIN GROWTH; 1-14 GROWTHS | 17110 | $88 |
| PATH CONSLTJ SURG 1 BLK 1SPC | 88331 | $90 |
| Comprehensive Metabolic Panel | 80053 | $91 |
| NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT; 15-29 MINUTES | 99202 | $101 |
| OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF ESTABLISHED PATIENT THAT MAY NOT REQUIRE PRESENCE OF HEALTHCARE PROFESSIONAL | 99211 | $101 |
| Mammogram (Screening) | 77067 | $105 |
| EMERGENCY DEPARTMENT VISIT FOR PROBLEM OF MODERATE SEVERITY | 99283 | $129 |
| DETECTION TEST BY NUCLEIC ACID FOR NEISSERIA GONORRHOEAE (GONORRHOEAE BACTERIA); AMPLIFIED PROBE TECHNIQUE | 87591 | $131 |
| HZV VACC RECOMBINANT IM | 90750 | $135 |
| PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE | 88302 | $139 |
| Office Visit (Established Patient) | 99213 | $141 |
| TSH Thyroid Test | 84443 | $144 |
| PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE; MODERATELY LOW COMPLEXITY | 88304 | $158 |
| ADMINISTRATION OF VACCINE | 90471 | $171 |
| Office Visit (New Patient) | 99203 | $174 |
| Office Visit (Complex) | 99214 | $179 |
| PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE; INTERMEDIATE COMPLEXITY | 88305 | $190 |
| SPECIAL STAINS GROUP 1 | 88312 | $193 |
| Head CT Scan | 70450 | $197 |
| DETECTION TEST BY NUCLEIC ACID FOR CHLAMYDIA TRACHOMATIS; AMPLIFIED PROBE TECHNIQUE | 87491 | $198 |
| SIMPLE REPAIR OF SURFACE WOUND OF SCALP; NECK; UNDERARMS; TRUNK; ARMS; OR LEGS; 2.5 CM OR LESS | 12001 | $205 |
| OFFICE O/P EST HI 40 MIN | 99215 | $224 |
| EMERGENCY DEPARTMENT VISIT FOR PROBLEM OF HIGH SEVERITY | 99284 | $244 |
| DXA BONE DENSITY APPENDICULR | 77081 | $244 |
| SIMPLE OR SINGLE DRAINAGE OF SKIN ABSCESS | 10060 | $246 |
| Office Visit (New, Complex) | 99204 | $282 |
| RMVL SKIN TAGS UP TO&INC 15 | 11200 | $299 |
| Knee MRI | 73721 | $315 |
| SHAVE SKIN LESION 0.5 CM/< | 11300 | $319 |
| SHAVE SKIN LESION 0.6-1.0 CM | 11301 | $324 |
| Lumbar Spine MRI | 72148 | $345 |
| Cervical Spine MRI | 72141 | $345 |
| PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE; MODERATELY HIGH COMPLEXITY | 88307 | $355 |
| EMERGENCY DEPARTMENT VISIT FOR LIFE THREATENING OR FUNCTIONING SEVERITY | 99285 | $359 |
| INFUSION INTO A VEIN FOR HYDRATION; 31-60 MINUTES | 96360 | $365 |
| Colonoscopy with Biopsy | 45380 | $377 |
| NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT; 60-74 MINUTES | 99205 | $380 |
| Colonoscopy | 45378 | $440 |
| PATHOLOGY EXAMINATION OF TISSUE USING A MICROSCOPE; HIGH COMPLEXITY | 88309 | $486 |
| Upper Endoscopy with Biopsy | 43239 | $517 |
| Brain MRI with Contrast | 70553 | $528 |
| INCISION OF EARDRUM WITH PLACEMENT OF EARDRUM TUBE UNDER GENERAL ANESTHESIA | 69436 | $570 |
| BIOPSY OF PROSTATE GLAND | 55700 | $630 |
| DIAGNOSTIC EXAM OF ESOPHAGUS; STOMACH; AND/OR UPPER SMALL BOWEL USING A FLEXIBLE ENDOSCOPE | 43235 | $689 |
| REMOVAL OF POLYPS OR GROWTHS OF LARGE BOWEL USING AN ENDOSCOPE WITH MECHANICAL SNARE | 45385 | $689 |
| Echocardiogram | 93306 | $970 |
| REMOVAL OF NASAL AIR PASSAGE UNDER LINING TISSUE | 30140 | $1,251 |
| REMOVAL OF KNEE CARTILAGE USING AN ENDOSCOPE | 29881 | $1,453 |
| Epidural Steroid Injection | 64483 | $1,709 |
| RESHAPING OF NASAL CARTILAGE | 30520 | $2,164 |
| REMOVAL OF APPENDIX USING AN ENDOSCOPE | 44970 | $2,194 |
| REMOVAL OF TONSILS AND ADENOID GLANDS (YOUNGER THAN 12 YEARS) | 42820 | $2,341 |
| Laparoscopic Cholecystectomy | 47562 | $2,401 |
| REMOVAL OF PROSTATE GLAND USING AN ELECTROCAUTERY KNIFE THROUGH URETHRA WITH CONTROL OF BLEEDING USING AN ENDOSCOPE | 52601 | $2,667 |
| Shoulder Arthroscopy | 29827 | $2,886 |
| POLYSOM 6/> YRS 4/> PARAM | 95810 | $2,887 |
| REPAIR OF ANTERIOR CRUCIATE LIGAMENT OF KNEE USING AN ENDOSCOPE | 29888 | $2,891 |
| Total Knee Replacement | 27447 | $3,468 |
| Total Hip Replacement | 27130 | $3,472 |
| PARTIAL REMOVAL OF BREAST | 19301 | $4,041 |
| REMOVAL OF BREAST AND UNDERARM LYMPH NODES | 19307 | $8,991 |
| TREATMENT OF UPPER END OF BROKEN THIGH BONE WITH PLACEMENT OF STABILIZING DEVICE OR PROSTHETIC REPLACEMENT | 27236 | $13,557 |
| REVISION OF THIGH AND LOWER LEG BONE COMPONENTS OF TOTAL KNEE JOINT PROSTHESIS | 27487 | $19,947 |