| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $3 | $3 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $241 | $241 | $241 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $422 | $422 | $422 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $543 | $543 | $543 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $543 | $543 | $543 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $483 | $483 | $483 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $362 | $362 | $362 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,264 | $1,264 | $1,264 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $2,230 | $2,230 | $2,230 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $5,316 | $5,316 | $5,316 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,377 | $2,377 | $2,377 |
| 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 | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $175 | $175 | $175 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $184 | $184 | $184 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $217 | $217 | $217 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $491 | $491 | $491 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $596 | $596 | $596 |
| Stress echocardiography CPT 93350 • Cardiology | $467 | $467 | $467 |
| Left and right heart catheterization CPT 93452 • Cardiology | $675 | $675 | $675 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $2,845 | $2,845 | $2,845 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $186 | $186 | $186 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $79 | $79 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $235 | $235 | $235 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $123 | $123 | $123 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $152 | $152 | $152 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $119 | $119 | $119 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $101 | $101 | $101 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $193 | $193 | $193 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $237 | $237 | $237 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $109 | $109 | $109 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $128 | $128 | $128 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $112 | $112 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $152 | $152 | $152 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |