| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $7 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $24 | $24 | $24 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $1 | $1 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $18 | $18 | $18 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $42 | $42 | $42 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,915 | $2,915 | $2,915 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $678 | $678 | $678 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $16 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $16 | $16 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $119 | $119 | $119 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $40 | $40 | $40 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $88 | $88 | $88 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $132 | $132 | $133 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $234 | $234 | $234 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $284 | $284 | $284 |
| Stress echocardiography CPT 93350 • Cardiology | $223 | $223 | $223 |
| Left and right heart catheterization CPT 93452 • Cardiology | $273 | $273 | $273 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,359 | $1,359 | $1,359 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $96 | $96 | $96 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $287 | $287 | $287 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $183 | $183 | $183 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $75 | $75 | $75 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $130 | $130 | $130 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $162 | $162 | $162 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $106 | $106 | $106 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $126 | $126 | $126 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $107 | $107 | $107 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $117 | $117 | $117 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $251 | $251 | $251 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $173 | $173 | $173 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $136 | $136 | $136 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $137 | $137 | $137 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $185 | $185 | $185 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |