| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $14 | $14 |
| 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 | $501 | $501 | $501 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $883 | $883 | $883 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,102 | $2,102 | $2,102 |
| 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 | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $64 | $64 | $64 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $71 | $71 | $71 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $100 | $100 | $100 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $59 | $59 | $59 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $186 | $186 | $186 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $227 | $227 | $228 |
| Stress echocardiography CPT 93350 • Cardiology | $176 | $176 | $176 |
| Left and right heart catheterization CPT 93452 • Cardiology | $215 | $215 | $215 |
| Left heart catheterization CPT 93458 • Cardiology | $268 | $268 | $268 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,080 | $1,080 | $1,080 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $76 | $76 | $76 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $228 | $228 | $228 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $54 | $54 | $54 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $100 | $100 | $100 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $122 | $122 | $122 |
| 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 | $96 | $96 | $96 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $155 | $155 | $155 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $192 | $192 | $192 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $97 | $97 | $97 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $128 | $128 | $128 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $87 | $87 | $87 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $102 | $102 | $103 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $106 | $106 | $106 |