| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $8 | $9 | $11 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $40 | $40 | $40 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $232 | $232 | $232 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $282 | $282 | $282 |
| Stress echocardiography CPT 93350 • Cardiology | $221 | $221 | $221 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $224 | $224 | $224 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $283 | $283 | $283 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $220 | $220 | $220 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $183 | $183 | $183 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $36 | $65 | $94 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $349 | $349 | $349 |
| Septoplasty CPT 30520 • ENT | $799 | $799 | $799 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $300 | $300 | $300 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $311 | $311 | $311 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $444 | $444 | $444 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $342 | $342 | $342 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $357 | $357 | $357 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $299 | $299 | $299 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $248 | $248 | $248 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $36 | $36 | $36 |
| Tympanostomy tube insertion CPT 69436 • ENT | $187 | $187 | $187 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $145 | $145 | $145 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $249 | $249 | $249 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $53 | $81 | $110 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $132 | $132 | $132 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $131 | $131 | $131 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $92 | $92 | $92 |
| Emergency department visit low severity CPT 99282 • Emergency | $69 | $80 | $92 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $94 | $94 | $94 |
| Emergency department visit high severity CPT 99284 • Emergency | $183 | $183 | $183 |
| Emergency department visit highest severity CPT 99285 • Emergency | $229 | $229 | $229 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $326 | $326 | $326 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $128 | $136 | $143 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $355 | $355 | $355 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $454 | $454 | $454 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $460 | $460 | $460 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $1,321 | $1,321 | $1,321 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $599 | $599 | $599 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $221 | $221 | $221 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $216 | $216 | $216 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $521 | $521 | $521 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $36 | $284 | $532 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $586 | $586 | $586 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $544 | $544 | $544 |
| Auto-added CPT 10120 • General | $175 | $175 | $175 |
| Auto-added CPT 10140 • General | $199 | $199 | $199 |
| Auto-added CPT 19083 • General | $606 | $606 | $606 |
| Auto-added CPT 19084 • General | $462 | $462 | $462 |