| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $6 | $6 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $17 | $17 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $18 | $18 | $18 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $28 | $28 | $28 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $79 | $79 | $79 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $108 | $108 | $108 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $158 | $158 | $158 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $99 | $99 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $167 | $167 | $167 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $158 | $158 | $158 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $88 | $88 | $88 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $178 | $178 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $147 | $147 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $198 | $198 | $198 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $128 | $128 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $2,219 | $2,219 | $2,219 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $860 | $860 | $860 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $11 | $11 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $15 | $15 | $15 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $62 | $62 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $59 | $59 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $243 | $243 | $243 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $53 | $53 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $91 | $91 |
| Left heart catheterization CPT 93458 • Cardiology | $445 | $445 | $445 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $136 | $136 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $62 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $171 | $171 | $171 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $138 | $138 | $138 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $58 | $58 | $58 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $70 | $70 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $82 | $82 | $82 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $88 | $88 | $88 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $69 | $69 | $69 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $84 | $84 | $84 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $80 | $80 | $80 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $129 | $129 | $129 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $73 | $73 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $103 | $103 | $103 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $96 | $96 | $96 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $117 | $117 | $117 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $81 | $81 | $81 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $200 | $200 | $200 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $73 | $73 | $73 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $14 | $14 | $14 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $38 | $38 | $38 |