| 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 | $19 | $19 | $19 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $35 | $35 | $35 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,371 | $2,371 | $2,371 |
| 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 | $68 | $68 | $68 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $65 | $65 | $65 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $248 | $248 | $248 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $180 | $180 | $180 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $216 | $216 | $217 |
| Stress echocardiography CPT 93350 • Cardiology | $169 | $169 | $169 |
| Left and right heart catheterization CPT 93452 • Cardiology | $793 | $793 | $793 |
| Left heart catheterization CPT 93458 • Cardiology | $654 | $654 | $654 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $990 | $990 | $990 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $34 | $34 | $34 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $74 | $74 | $74 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $214 | $214 | $214 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $60 | $60 | $60 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $70 | $70 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $85 | $85 | $85 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $106 | $106 | $106 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $132 | $132 | $132 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $85 | $85 | $85 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $103 | $103 | $103 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $148 | $148 | $148 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $212 | $212 | $212 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $115 | $115 | $115 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $106 | $106 | $106 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $128 | $128 | $128 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $4 | $4 | $4 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $70 | $70 | $70 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $44 | $44 | $44 |