| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $11 | $11 | $11 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $98 | $98 | $98 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $132 | $132 | $132 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $120 | $120 | $120 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $154 | $154 | $154 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $140 | $140 | $140 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $176 | $176 | $176 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $297 | $297 | $297 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $120 | $120 | $120 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $490 | $490 | $490 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $12 | $12 | $12 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $4 | $4 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $53 | $53 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $131 | $131 | $131 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $9 | $9 | $9 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $163 | $163 | $163 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $126 | $126 | $126 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $69 | $69 | $69 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $86 | $86 | $86 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $41 | $41 | $41 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $62 | $62 | $62 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $201 | $201 | $201 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $86 | $86 | $86 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $89 | $89 | $89 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $49 | $49 | $49 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $117 | $117 | $117 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $81 | $81 | $81 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $112 | $112 | $112 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $78 | $78 | $78 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $22 | $22 | $22 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $11 | $11 | $11 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $121 | $121 | $121 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $40 | $40 | $40 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $101 | $101 | $101 |
| Septoplasty CPT 30520 • ENT | $513 | $513 | $513 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $127 | $127 | $127 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $40 | $40 | $40 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $31 | $31 | $31 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $90 | $90 | $90 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $160 | $160 | $160 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $39 | $39 | $39 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $52 | $52 | $52 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $50 | $50 | $50 |