| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $5 | $5 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $12 | $12 | $12 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $12 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $112 | $112 | $112 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $386 | $386 | $386 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $89 | $89 | $89 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $168 | $168 | $168 |
| Left heart catheterization CPT 93458 • Cardiology | $431 | $431 | $431 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $231 | $231 | $231 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $58 | $58 | $58 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $290 | $290 | $290 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $124 | $124 | $124 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $83 | $83 | $83 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $104 | $104 | $104 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $76 | $76 | $76 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $80 | $80 | $80 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $48 | $48 | $48 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $128 | $128 | $128 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $73 | $73 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $105 | $105 | $105 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $53 | $53 | $53 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $82 | $82 | $82 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $91 | $91 | $91 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $12 | $12 | $12 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $96 | $96 | $96 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $31 | $31 | $31 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $47 | $47 | $47 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $177 | $177 | $177 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $1,472 | $1,472 | $1,472 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $36 | $36 | $36 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $117 | $117 | $117 |
| Septoplasty CPT 30520 • ENT | $574 | $574 | $574 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $106 | $106 | $106 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $237 | $237 | $237 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $256 | $256 | $256 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $87 | $87 | $87 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $62 | $62 | $62 |
| Tympanostomy tube insertion CPT 69436 • ENT | $208 | $208 | $208 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $32 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $93 | $93 | $93 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $268 | $268 | $268 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $90 | $90 | $90 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $111 | $111 | $111 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $201 | $201 | $201 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $238 | $238 | $238 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $66 | $66 | $66 |