| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $7 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $5 | $6 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $28 | $28 | $28 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $10 | $10 |
| 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 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,815 | $1,815 | $1,815 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,130 | $2,130 | $2,130 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,370 | $2,370 | $2,370 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $652 | $652 | $652 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $422 | $422 | $422 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $20 | $20 | $20 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $9 | $9 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $11 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $101 | $101 | $101 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $117 | $117 | $117 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $89 | $124 | $158 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $299 | $299 | $299 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $158 | $158 |
| Stress echocardiography CPT 93350 • Cardiology | $50 | $50 | $50 |
| Left and right heart catheterization CPT 93452 • Cardiology | $145 | $145 | $145 |
| Left heart catheterization CPT 93458 • Cardiology | $525 | $525 | $525 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,767 | $1,767 | $1,767 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $121 | $121 | $121 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $119 | $119 | $119 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $356 | $356 | $356 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $11 | $34 | $57 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $50 | $50 | $50 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $28 | $28 | $28 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $81 | $81 | $81 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $100 | $100 | $100 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $80 | $80 | $80 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $190 | $190 | $190 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $85 | $85 | $85 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $52 | $52 | $52 |