| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $7 | $7 | $7 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $19 | $19 | $19 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $496 | $496 | $496 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $752 | $752 | $752 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $542 | $542 | $542 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $408 | $408 | $408 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $620 | $620 | $620 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $510 | $510 | $510 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $389 | $389 | $389 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $267 | $267 | $267 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $578 | $578 | $578 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $533 | $533 | $533 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $587 | $587 | $587 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $521 | $521 | $521 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $730 | $730 | $730 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $1,243 | $1,243 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,580 | $2,580 | $2,580 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,872 | $3,872 | $3,872 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $803 | $803 | $803 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $24 | $27 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $12 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $96 | $96 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $43 | $43 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $311 | $311 | $311 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $102 | $102 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $124 | $124 | $124 |
| Stress echocardiography CPT 93350 • Cardiology | $156 | $156 | $156 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $403 | $403 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $465 | $465 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $265 | $265 | $265 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $113 | $113 | $113 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $330 | $330 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $61 | $61 | $61 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $132 | $132 | $132 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $67 | $67 | $67 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $67 | $67 | $67 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $163 | $163 | $163 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $156 | $156 | $156 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $169 | $169 | $169 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $206 | $206 | $206 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $225 | $225 | $225 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $167 | $167 | $167 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $88 | $88 | $88 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $3 | $3 | $3 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $209 | $209 | $209 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $150 | $150 | $150 |