| 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 |
| 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 complete CPT 93306 • Cardiology | $53 | $53 | $53 |
| 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 | $62 | $62 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $178 | $178 | $178 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $138 | $138 | $138 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $95 | $95 | $95 |
| 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 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $1,302 | $1,302 | $1,302 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $133 | $133 | $133 |
| 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 | $32 | $32 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $94 | $94 | $94 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $155 | $155 | $155 |
| 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 high severity CPT 99284 • Emergency | $113 | $113 | $113 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $198 | $198 | $198 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $144 | $144 | $144 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $115 | $115 | $115 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $118 | $118 | $118 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $113 | $113 | $113 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $207 | $207 | $207 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $525 | $525 | $525 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $214 | $214 | $214 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $167 | $167 | $167 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $116 | $116 | $116 |