| 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 | $4 | $7 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $23 | $23 | $23 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $15 | $15 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $30 | $30 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $1,371 | $2,712 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $18 | $18 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $9 | $9 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $9 | $9 |
| Cardiovascular stress test CPT 93015 • Cardiology | $78 | $78 | $78 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $36 | $36 | $36 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $98 | $98 | $98 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $80 | $175 | $270 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $228 | $228 | $228 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $30 | $132 | $234 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $30 | $30 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,265 | $1,265 | $1,265 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $91 | $91 | $91 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $270 | $270 | $270 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $76 | $76 | $76 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $30 | $30 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $107 | $107 | $107 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $137 | $137 | $137 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $166 | $166 | $166 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $108 | $108 | $108 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $150 | $150 | $150 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $143 | $255 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $141 | $141 | $141 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $85 | $140 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $120 | $120 | $120 |