| HC ADMIN HEPATITIS B VACCINE CDM | 90471 | $11 |
| HC BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER CDM | 82270 | $19 |
| HC URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY LAB | 81001 | $21 |
| Blood Glucose Test | 82947 | $27 |
| HC CHOLESTEROL | 82465 | $32 |
| Complete Blood Count (CBC) | 85025 | $48 |
| HC LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY LAB | 88300 | $54 |
| Comprehensive Metabolic Panel | 80053 | $56 |
| Therapeutic Injection | 96372 | $69 – $126 |
| Hemoglobin A1c | 83036 | $70 |
| HC HIV-1/HIV-2 SINGLE ASSAY | 86703 | $72 |
| Lipid Panel | 80061 | $77 |
| HC LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88302 | $96 |
| HC SPECIAL STAIN GROUP 1 MICROORGANISMS I&R LAB | 88312 | $97 |
| HC XR SHOULDER COMPLETE MIN 2 VIEWS | 73030 | $106 – $264 |
| DEXA Bone Density Scan | 77080 | $106 – $264 |
| HC BONE DENSITY PERIPHERAL SKELETON | 77081 | $106 – $264 |
| Knee X-Ray | 73560 | $106 – $264 |
| HC XR CHEST 1 VIEW | 71045 | $107 – $323 |
| Chest X-Ray (2 Views) | 71046 | $107 – $323 |
| HC LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88304 | $114 |
| TSH Thyroid Test | 84443 | $115 |
| HC PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC LAB | 88331 | $120 |
| HC ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL LAB | 84153 | $125 |
| HC CONSLTJ&REPRT MATERIAL REQUIRING PREPJ SLIDES LAB | 88323 | $127 |
| HC LEVEL IV SURG PATHOLOGY GROSS AND MICROSCOPIC EXAM LAB | 88305 | $138 |
| HC ED OB FAC E&M VISIT LEVEL 1 CDM | 99281 | $160 |
| Mammogram (Screening) | 77067 | $174 – $534 |
| Head CT Scan | 70450 | $192 – $304 |
| HC PR 90791 PSYCH DIAG EVAL RHC | 90791 | $199 |
| HC PR 90832 PSYTX W PT 30 MIN RHC | 90832 | $203 |
| HC IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ LAB | 87491 | $211 |
| HC IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ LAB | 87591 | $211 |
| HC IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES LAB | 87624 | $211 |
| HC IV HYDRATION INITIAL HR CDM | 96360 | $234 – $430 |
| HC LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88307 | $252 |
| HC ED OB FAC E&M VISIT LEVEL 2 CDM | 99282 | $289 |
| HC INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE CDM | 10060 | $301 – $551 |
| HC SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/OR LESS CDM | 11305 | $301 – $551 |
| HC ED SHAVE SKIN LESION 0.5 CM OR LESS TRNK ARM LEG CDM | 11300 | $301 – $551 |
| HC SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/OR LESS | 12001 | $301 – $551 |
| HC DESTRUCTION BENIGN LESIONS UP TO 14 CDM | 17110 | $301 – $551 |
| HC SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM CDM | 11301 | $301 – $551 |
| HC DESTRUCTION BENIGN LESIONS 15/> CDM | 17111 | $301 – $551 |
| HC LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM LAB | 88309 | $319 |
| HC REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 | 11200 | $360 |
| HC PR 90834 PSYTX W PT 45 MIN RHC | 90834 | $376 |
| Psychotherapy (60 min) | 90837 | $376 |
| ZOSTER VAC RECOMBINANT ADJUVANTED FOR IM INJ 50 MCG/0.5ML | 90750 | $417 |
| HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US | 20610 | $497 – $911 |
| Knee MRI | 73721 | $498 – $1,016 |
| Lumbar Spine MRI | 72148 | $519 – $1,057 |
| Cervical Spine MRI | 72141 | $539 – $1,038 |
| HC ED OB FAC E&M VISIT LEVEL 3 CDM | 99283 | $549 |
| HC ED INCISION OF EARDRUM W/O GENERAL ANESTHESIA CDM | 69420 | $636 |
| HC ED BH FAC E&M LEVEL 4 CDM | 99284 | $866 |
| HC ED EXCISION CHALAZION SINGLE CDM | 67800 | $960 |
| HC DIAGNOSTIC GASTROSCOPE | 43235 | $997 – $1,829 |
| HC EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/OR LESS CDM | 11400 | $1,037 – $1,900 |
| HC EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/OR LESS CDM | 11440 | $1,037 – $1,900 |
| HC EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM | 11401 | $1,089 – $1,957 |
| Brain MRI with Contrast | 70553 | $1,152 – $2,219 |
| Echocardiogram | 93306 | $1,192 – $2,387 |
| HC ED OB FAC E&M VISIT LEVEL 5 CDM | 99285 | $1,272 |
| Epidural Steroid Injection | 64483 | $1,387 – $2,542 |
| Upper Endoscopy with Biopsy | 43239 | $1,829 |
| Colonoscopy | 45378 | $1,932 |
| HC POLYSOMNOGRAPHY 4 OR MORE | 95810 | $1,946 – $4,476 |
| HC POLYSOMNOGRAPHY 1-3 | 95808 | $1,946 – $4,476 |
| HC BX BREAST PERCUT W/O IMAGE | 19100 | $2,411 – $4,420 |
| HC BIOPSY OF PROSTATE | 55700 | $3,202 – $5,869 |
| HC ED CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ CDM | 27238 | $4,357 |
| HC PARTIAL MASTECTOMY | 19301 | $8,856 |
| HC P-MASTECTOMY W/LN REMOVAL | 19302 | $15,565 |