| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $12 | $12 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $137 | $137 | $137 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $170 | $170 | $170 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $139 | $139 | $139 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $1,450 | $1,450 | $1,450 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $485 | $485 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $4 | $4 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $62 | $62 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $224 | $224 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $59 | $59 | $59 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $66 | $66 | $66 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $251 | $251 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $285 | $285 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $136 | $136 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $16 | $16 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $38 | $38 | $38 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $171 | $171 | $171 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $31 | $31 | $31 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $86 | $86 | $86 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $41 | $41 | $41 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $100 | $100 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $66 | $66 | $66 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $73 | $73 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $94 | $94 | $94 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $112 | $112 | $112 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $13 | $13 | $13 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $60 | $60 | $60 |
| Septoplasty CPT 30520 • ENT | $558 | $558 | $558 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $58 | $58 | $58 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $329 | $329 | $329 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $42 | $42 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $206 | $206 | $206 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $34 | $34 | $34 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $94 | $94 | $94 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $178 | $178 | $178 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $72 | $72 | $72 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $223 | $223 | $223 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $121 | $121 | $121 |
| Emergency department visit low severity CPT 99282 • Emergency | $43 | $43 | $43 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $74 | $74 | $74 |
| Emergency department visit high severity CPT 99284 • Emergency | $166 | $166 | $166 |
| Emergency department visit highest severity CPT 99285 • Emergency | $233 | $233 | $233 |