| Allergen specific IgE each allergen CPT 86003 • Allergy | $10 | $10 | $10 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $21 | $21 | $21 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $80 | $80 | $80 |
| Stress echocardiography CPT 93350 • Cardiology | $182 | $182 | $182 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $230 | $230 | $230 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $104 | $104 | $104 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $45 | $45 | $45 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $59 | $59 | $59 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $104 | $104 | $104 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $354 | $354 | $354 |
| Septoplasty CPT 30520 • ENT | $524 | $524 | $524 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $543 | $543 | $543 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $265 | $265 | $265 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $356 | $356 | $356 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $317 | $317 | $317 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $250 | $250 | $250 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $60 | $60 | $60 |
| Tympanostomy tube insertion CPT 69436 • ENT | $201 | $201 | $201 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $114 | $114 | $114 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $205 | $205 | $205 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $178 | $178 | $178 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $44 | $44 | $44 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $188 | $188 | $188 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $44 | $129 | $214 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $272 | $272 | $272 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $21 | $21 | $21 |
| Emergency department visit low severity CPT 99282 • Emergency | $35 | $35 | $35 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $77 | $77 | $77 |
| Emergency department visit high severity CPT 99284 • Emergency | $120 | $120 | $120 |
| Emergency department visit highest severity CPT 99285 • Emergency | $188 | $188 | $188 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $305 | $305 | $305 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $136 | $136 | $136 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $349 | $349 | $349 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $397 | $397 | $397 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $235 | $235 | $235 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $203 | $203 | $203 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $255 | $255 | $255 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $148 | $148 | $148 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $579 | $579 | $579 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $615 | $615 | $615 |
| Auto-added CPT 10120 • General | $129 | $129 | $129 |
| Auto-added CPT 13131 • General | $368 | $368 | $368 |
| Auto-added CPT 13132 • General | $512 | $512 | $512 |
| Auto-added CPT 73220 • General | $44 | $44 | $44 |
| Auto-added CPT 80150 • General | $14 | $14 | $14 |
| Auto-added CPT 81025 • General | $9 | $9 | $9 |
| Auto-added CPT 81050 • General | $3 | $3 | $3 |
| Auto-added CPT 82040 • General | $3 | $3 | $3 |