| Allergen specific IgE each allergen CPT 86003 • Allergy | $10 | $10 | $10 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $10 | $10 | $10 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $15 | $15 | $15 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $19 | $19 | $19 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $15 | $15 | $15 |
| Sublingual allergen immunotherapy CPT 95199 • Allergy | $48 | $48 | $48 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $48 | $48 | $48 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,549 | $1,549 | $1,549 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,688 | $1,688 | $1,688 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,365 | $3,365 | $3,365 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,164 | $4,164 | $4,164 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,703 | $4,703 | $4,703 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $45 | $45 | $45 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $22 | $22 | $22 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $26 | $26 | $26 |
| Cardiovascular stress test CPT 93015 • Cardiology | $212 | $212 | $212 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $80 | $80 | $80 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $229 | $229 | $229 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $259 | $259 | $259 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $366 | $366 | $366 |
| Stress echocardiography CPT 93350 • Cardiology | $196 | $196 | $196 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $72 | $72 | $72 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $22 | $22 | $22 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $319 | $319 | $319 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $208 | $208 | $208 |
| Unlisted dental procedure CPT 41899 • Dental | $230 | $230 | $230 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $22 | $22 | $22 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $50 | $50 | $50 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $68 | $68 | $68 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $52 | $52 | $52 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $64 | $64 | $64 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $134 | $134 | $134 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $174 | $174 | $174 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $210 | $210 | $210 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $163 | $163 | $163 |