| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $7 | $7 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $3 | $3 |
| 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 | $48 | $48 | $48 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,191 | $2,191 | $2,191 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $48 | $1,311 | $2,573 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,869 | $2,869 | $2,869 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $568 | $568 | $568 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $113 | $113 | $113 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $66 | $66 | $66 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $207 | $207 | $207 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $48 | $151 | $255 |
| Stress echocardiography CPT 93350 • Cardiology | $48 | $48 | $48 |
| Left heart catheterization CPT 93458 • Cardiology | $1,124 | $1,124 | $1,124 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $41 | $41 | $41 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $214 | $214 | $214 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $65 | $65 | $66 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $75 | $75 | $75 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $97 | $97 | $97 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $48 | $48 | $48 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $37 | $37 | $37 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $112 | $112 | $112 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $79 | $79 | $79 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $48 | $48 | $48 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $48 | $48 | $48 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $48 | $143 | $237 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $48 | $48 | $48 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $96 | $96 | $96 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $63 | $63 | $63 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $48 | $48 | $48 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $48 | $48 | $48 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $48 | $87 | $126 |