| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $3 | $3 |
| Emergency department visit high severity CPT 99284 • Emergency | $118 | $118 | $118 |
| Influenza virus assay with direct optical CPT 87804 • Laboratory | $13 | $13 | $13 |
| Office visit new patient straightforward CPT 99202 • Office Visits | $53 | $53 | $53 |
| Office visit new patient low complexity CPT 99203 • Office Visits | $30 | $30 | $30 |
| Office visit new patient moderate complexity CPT 99204 • Office Visits | $30 | $30 | $30 |
| Office visit new patient high complexity CPT 99205 • Office Visits | $30 | $30 | $30 |
| Office visit established patient minimal CPT 99211 • Office Visits | $30 | $30 | $30 |
| Office visit established patient straightforward CPT 99212 • Office Visits | $30 | $30 | $30 |
| Office visit established patient low complexity CPT 99213 • Office Visits | $30 | $30 | $30 |
| Office visit established patient moderate complexity CPT 99214 • Office Visits | $30 | $30 | $30 |
| Office visit established patient high complexity CPT 99215 • Office Visits | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $30 | $30 |
| Immunization admin injection single CPT 90471 • Preventive Care | $10 | $10 | $10 |
| Pneumococcal vaccine adult CPT 90732 • Preventive Care | $133 | $133 | $133 |
| Spirometry CPT 94010 • Pulmonology | $30 | $30 | $30 |