| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $12 | $12 | $12 |
| 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 | $28 | $28 | $28 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $160 | $160 | $160 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $194 | $194 | $194 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $113 | $113 | $113 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $364 | $364 | $364 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $180 | $180 | $180 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $196 | $196 | $196 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $376 | $376 | $376 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $243 | $243 | $243 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $196 | $196 | $196 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $212 | $212 | $212 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $311 | $311 | $311 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $413 | $413 | $413 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $789 | $789 | $789 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,592 | $1,592 | $1,592 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,867 | $1,867 | $1,867 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $860 | $860 | $860 |
| 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 | $16 | $16 | $16 |
| Cardiovascular stress test CPT 93015 • Cardiology | $115 | $115 | $115 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $90 | $90 | $90 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $259 | $259 | $259 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $46 | $46 | $46 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $292 | $292 | $292 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $169 | $169 | $169 |
| Left heart catheterization CPT 93458 • Cardiology | $445 | $445 | $445 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $287 | $287 | $287 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $29 | $167 | $306 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $9 | $74 | $139 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $28 | $219 | $411 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $51 | $178 | $304 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $61 | $61 | $61 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $122 | $122 | $122 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $83 | $83 | $83 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $157 | $157 | $157 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $154 | $154 | $154 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $44 | $44 | $44 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $97 | $97 | $97 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $54 | $54 | $54 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $136 | $136 | $136 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $177 | $177 | $177 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $105 | $105 | $105 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $172 | $172 | $172 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $58 | $58 | $58 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |