| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $12 | $12 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $236 | $236 | $236 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $138 | $138 | $138 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $219 | $219 | $219 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $315 | $315 | $315 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $177 | $177 | $177 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $179 | $179 | $179 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $417 | $417 | $417 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $315 | $315 | $315 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $217 | $217 | $217 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $238 | $238 | $238 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $167 | $167 | $167 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $528 | $528 | $528 |
| 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 | $63 | $63 | $63 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $65 | $65 | $65 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $102 | $102 | $102 |
| Left heart catheterization CPT 93458 • Cardiology | $264 | $264 | $264 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $36 | $36 | $36 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $57 | $57 | $57 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $34 | $34 | $34 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $133 | $133 | $133 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $56 | $56 | $56 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $68 | $68 | $68 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $99 | $99 | $99 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $97 | $97 | $97 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $85 | $85 | $85 |
| 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 | $71 | $71 | $71 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $81 | $81 | $81 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $85 | $85 | $85 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $79 | $79 | $79 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $47 | $47 | $47 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $4 | $4 | $4 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $135 | $135 | $135 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $92 | $92 | $92 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $79 | $79 | $79 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $78 | $78 | $78 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $33 | $33 | $33 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $121 | $121 | $121 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $39 | $39 | $39 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,426 | $1,426 | $1,426 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $34 | $34 | $34 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $89 | $89 | $89 |