| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $7 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $7 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $5 | $5 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $9 | $9 | $9 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $40 | $40 |
| 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 | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $40 | $40 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $483 | $483 | $483 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,029 | $2,029 | $2,029 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $16 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $8 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $75 | $75 | $75 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $42 | $42 | $42 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $85 | $85 | $85 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $63 | $63 | $64 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $109 | $109 | $109 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $193 | $193 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $252 | $252 | $253 |
| Stress echocardiography CPT 93350 • Cardiology | $165 | $165 | $165 |
| Left and right heart catheterization CPT 93452 • Cardiology | $487 | $487 | $487 |
| Left heart catheterization CPT 93458 • Cardiology | $294 | $294 | $294 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $999 | $999 | $999 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $93 | $93 | $93 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $148 | $148 | $148 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $40 | $40 | $40 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $35 | $35 | $35 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $105 | $105 | $105 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $127 | $127 | $127 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $52 | $52 | $52 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $71 | $71 | $71 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $36 | $36 | $36 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $123 | $123 | $123 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $139 | $139 | $139 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $187 | $187 | $187 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $97 | $97 | $97 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |