| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| 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 | $685 | $685 | $685 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,446 | $2,677 | $2,907 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $571 | $571 | $571 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $16 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $9 | $9 |
| Cardiovascular stress test CPT 93015 • Cardiology | $80 | $80 | $80 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $34 | $34 | $34 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $81 | $81 | $81 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $253 | $271 | $289 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $153 | $153 | $153 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $220 | $220 | $220 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $125 | $176 | $228 |
| Stress echocardiography CPT 93350 • Cardiology | $209 | $209 | $209 |
| Left and right heart catheterization CPT 93452 • Cardiology | $273 | $273 | $273 |
| Left heart catheterization CPT 93458 • Cardiology | $722 | $722 | $722 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,252 | $1,252 | $1,252 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $77 | $77 | $77 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $227 | $227 | $227 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $178 | $178 | $178 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $56 | $56 | $56 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $18 | $18 | $18 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $115 | $115 | $115 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $142 | $142 | $142 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $79 | $79 | $79 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $112 | $112 | $112 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $31 | $31 | $31 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $86 | $86 | $86 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $182 | $182 | $182 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $200 | $213 | $226 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $103 | $103 | $103 |