| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $6 | $6 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $18 | $18 | $18 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $28 | $28 | $28 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $278 | $278 | $278 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $124 | $124 | $124 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $165 | $165 | $165 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $206 | $206 | $206 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $376 | $376 | $376 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $243 | $243 | $243 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $196 | $196 | $196 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $181 | $181 | $181 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $311 | $311 | $311 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $860 | $860 | $860 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $20 | $20 | $20 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $11 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $115 | $115 | $115 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $90 | $90 | $90 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $292 | $292 | $292 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $169 | $169 | $169 |
| Left heart catheterization CPT 93458 • Cardiology | $445 | $445 | $445 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $59 | $59 | $59 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $88 | $88 | $88 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $58 | $58 | $58 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $50 | $50 | $50 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $122 | $122 | $122 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $157 | $157 | $157 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $154 | $154 | $154 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $177 | $177 | $177 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $172 | $172 | $172 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $200 | $200 | $200 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $86 | $86 | $86 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $439 | $439 | $439 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $263 | $263 | $263 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $374 | $374 | $374 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $407 | $407 | $407 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $425 | $425 | $425 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $21 | $21 | $21 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $50 | $50 | $50 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $163 | $163 | $163 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $328 | $328 | $328 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $69 | $69 | $69 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $107 | $107 | $107 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $102 | $102 | $102 |
| Emergency department visit low severity CPT 99282 • Emergency | $54 | $54 | $54 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $131 | $131 | $131 |
| Emergency department visit high severity CPT 99284 • Emergency | $186 | $186 | $186 |
| Emergency department visit highest severity CPT 99285 • Emergency | $268 | $268 | $268 |