| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $14 | $14 |
| 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) single CPT 33533 • Cardiology | $30 | $30 | $30 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $30 | $30 |
| 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 | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $68 | $68 | $69 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $33 | $33 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $72 | $72 | $72 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $217 | $217 | $217 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $193 | $193 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $30 | $132 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $30 | $30 |
| Left and right heart catheterization CPT 93452 • Cardiology | $905 | $905 | $905 |
| Left heart catheterization CPT 93458 • Cardiology | $1,041 | $1,041 | $1,041 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $1,120 | $1,120 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $79 | $79 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $235 | $235 | $236 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $30 | $30 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $123 | $123 | $123 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $152 | $152 | $153 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $30 | $65 | $100 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $91 | $152 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $30 | $30 |