| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $10 | $10 | $10 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $15 | $15 | $15 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $17 | $17 | $17 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $21 | $21 | $21 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $1,480 | $1,480 | $1,480 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $740 | $740 | $740 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $888 | $888 | $888 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $1,036 | $1,036 | $1,036 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $1,036 | $1,036 | $1,036 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $1,332 | $1,332 | $1,332 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $1,480 | $1,480 | $1,480 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $1,110 | $1,110 | $1,110 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $1,406 | $1,406 | $1,406 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $1,332 | $1,332 | $1,332 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $1,036 | $1,036 | $1,036 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $1,776 | $1,776 | $1,776 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $1,184 | $1,184 | $1,184 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $920 | $920 | $920 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,051 | $1,051 | $1,051 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $29 | $29 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $15 | $15 | $15 |
| Cardiovascular stress test CPT 93015 • Cardiology | $129 | $129 | $129 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $153 | $153 | $153 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $396 | $396 | $396 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $537 | $537 | $537 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $211 | $211 | $211 |
| Stress echocardiography CPT 93350 • Cardiology | $124 | $124 | $124 |
| Left heart catheterization CPT 93458 • Cardiology | $541 | $541 | $541 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $337 | $337 | $337 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $149 | $149 | $149 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $68 | $68 | $68 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $60 | $60 | $60 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $157 | $157 | $157 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $200 | $200 | $200 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $250 | $250 | $250 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $139 | $139 | $139 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $111 | $111 | $111 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $9 | $9 | $9 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $185 | $185 | $185 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $96 | $96 | $96 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $117 | $117 | $117 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $1,117 | $1,117 | $1,117 |
| Septoplasty CPT 30520 • ENT | $530 | $530 | $530 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $352 | $352 | $352 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $439 | $439 | $439 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $326 | $326 | $326 |