| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $3 | $3 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $9 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $15 | $18 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $15 | $22 | $28 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $42 | $44 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $159 | $278 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $77 | $113 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $44 | $105 | $165 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $44 | $98 | $206 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $44 | $210 | $376 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $44 | $143 | $243 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $118 | $196 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $126 | $212 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $132 | $311 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,102 | $2,102 | $2,102 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $44 | $44 | $44 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $860 | $860 | $860 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $20 | $20 | $20 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $16 | $16 | $16 |
| Cardiovascular stress test CPT 93015 • Cardiology | $115 | $115 | $115 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $90 | $90 | $90 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $100 | $100 | $100 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $212 | $212 | $212 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $108 | $147 | $186 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $169 | $198 | $228 |
| Left heart catheterization CPT 93458 • Cardiology | $445 | $445 | $445 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $189 | $189 | $189 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $18 | $18 | $18 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $57 | $57 | $57 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $50 | $50 | $50 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $13 | $33 | $54 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $44 | $83 | $122 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $157 | $157 | $157 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $80 | $80 | $80 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $154 | $154 | $154 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $75 | $75 | $75 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $44 | $44 | $44 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $80 | $80 | $80 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $192 | $192 | $192 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $172 | $172 | $172 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $44 | $44 | $44 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $103 | $151 | $200 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |