| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $43 | $43 | $44 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $43 | $43 | $44 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $43 | $43 | $44 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $457 | $457 | $457 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,908 | $1,970 | $2,031 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $66 | $66 | $66 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $67 | $67 | $67 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $244 | $245 | $246 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $147 | $147 | $147 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $183 | $183 | $183 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $217 | $220 | $223 |
| Stress echocardiography CPT 93350 • Cardiology | $174 | $174 | $174 |
| Left heart catheterization CPT 93458 • Cardiology | $258 | $258 | $258 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,029 | $1,029 | $1,029 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $64 | $64 | $64 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $222 | $222 | $222 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $143 | $143 | $143 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $66 | $66 | $66 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $117 | $117 | $117 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $92 | $92 | $92 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $119 | $119 | $119 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $183 | $183 | $183 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $228 | $229 | $230 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $123 | $124 | $125 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $108 | $108 | $108 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $7 | $7 | $7 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $18 | $66 | $114 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $64 | $64 | $64 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $809 | $809 | $809 |