| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $16 | $16 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $11 | $11 | $11 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $117 | $117 | $117 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $409 | $409 | $409 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $62 | $62 | $62 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $85 | $85 | $85 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $424 | $424 | $424 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $373 | $373 | $373 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $114 | $114 | $114 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $143 | $143 | $143 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $149 | $149 | $149 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $342 | $342 | $342 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $359 | $359 | $359 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $365 | $365 | $365 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $279 | $279 | $279 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $677 | $677 | $677 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $12 | $12 | $12 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $87 | $87 | $87 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $66 | $66 | $66 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $150 | $150 | $150 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $141 | $141 | $141 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $111 | $111 | $111 |
| Left heart catheterization CPT 93458 • Cardiology | $242 | $242 | $242 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $275 | $275 | $275 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $28 | $28 | $28 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $58 | $58 | $58 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $159 | $159 | $159 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $174 | $174 | $174 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $70 | $70 | $70 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $70 | $70 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $97 | $97 | $97 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $118 | $118 | $118 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $145 | $145 | $145 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $85 | $85 | $85 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $155 | $155 | $155 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $142 | $142 | $142 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $42 | $42 | $42 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $66 | $66 | $66 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $161 | $161 | $161 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $109 | $109 | $109 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $11 | $11 | $11 |