| 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 | $6 | $6 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $15 | $15 | $15 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $11 | $11 | $11 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $50 | $50 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $630 | $630 | $630 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,112 | $1,112 | $1,112 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,632 | $2,632 | $2,633 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $509 | $509 | $509 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $11 | $11 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $4 | $4 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $6 | $6 | $6 |
| Cardiovascular stress test CPT 93015 • Cardiology | $57 | $57 | $57 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $61 | $61 | $61 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $111 | $111 | $111 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $163 | $163 | $163 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $197 | $197 | $198 |
| Stress echocardiography CPT 93350 • Cardiology | $155 | $155 | $155 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $942 | $942 | $942 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $82 | $82 | $82 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $245 | $245 | $245 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $72 | $72 | $72 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $21 | $21 | $21 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $126 | $126 | $126 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $156 | $156 | $156 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $102 | $102 | $102 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $122 | $122 | $122 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $50 | $50 | $50 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $44 | $44 | $44 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $197 | $197 | $197 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $242 | $242 | $243 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $112 | $112 | $112 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $131 | $131 | $132 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $117 | $117 | $117 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $158 | $158 | $158 |