| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $6 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $36 | $36 | $36 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $36 | $36 | $36 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $17 | $17 | $17 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $83 | $83 | $83 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $40 | $40 | $40 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $232 | $232 | $232 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $282 | $282 | $282 |
| Stress echocardiography CPT 93350 • Cardiology | $221 | $221 | $221 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $224 | $224 | $224 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $95 | $95 | $95 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $45 | $164 | $283 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $40 | $40 | $40 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $36 | $36 | $36 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $44 | $44 | $44 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $148 | $148 | $148 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $183 | $183 | $183 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $40 | $80 | $119 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $36 | $93 | $149 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $36 | $110 | $183 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $36 | $36 | $36 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $44 | $69 | $94 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $36 | $36 | $36 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $36 | $36 | $36 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $349 | $349 | $349 |
| Septoplasty CPT 30520 • ENT | $799 | $799 | $799 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $221 | $221 | $221 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $300 | $300 | $300 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $36 | $174 | $311 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $36 | $240 | $444 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $342 | $342 | $342 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $36 | $196 | $357 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $299 | $299 | $299 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $248 | $248 | $248 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $36 | $36 | $36 |
| Tympanostomy tube insertion CPT 69436 • ENT | $187 | $187 | $187 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $44 | $44 | $44 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $36 | $91 | $145 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $36 | $143 | $249 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $36 | $36 | $36 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $36 | $36 | $36 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $131 | $131 | $131 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $36 | $173 | $309 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $92 | $92 | $92 |
| Emergency department visit low severity CPT 99282 • Emergency | $92 | $92 | $92 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $80 | $87 | $94 |
| Emergency department visit high severity CPT 99284 • Emergency | $138 | $147 | $156 |