| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $7 | $7 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $292 | $292 | $292 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $292 | $292 | $292 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $292 | $292 | $292 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $195 | $195 | $195 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $341 | $341 | $341 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $438 | $438 | $438 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $341 | $341 | $341 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $292 | $292 | $292 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $438 | $438 | $438 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $389 | $389 | $389 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $292 | $292 | $292 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $389 | $389 | $389 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $292 | $292 | $292 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $16,026 | $16,026 | $16,026 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $43,926 | $43,926 | $43,926 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $57 | $57 | $57 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $57 | $57 | $57 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $57 | $57 | $57 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $36 | $36 | $36 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $209 | $209 | $209 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $41 | $148 | $202 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $198 | $198 | $198 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $57 | $57 | $57 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $57 | $57 | $57 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $57 | $57 | $57 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $57 | $57 | $57 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $57 | $57 | $57 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $57 | $57 | $57 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $57 | $57 | $57 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $57 | $57 | $57 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $57 | $57 | $57 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $13,476 | $13,476 | $13,476 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $13,476 | $13,476 | $13,476 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $57 | $71 | $85 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $57 | $57 | $57 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $57 | $57 | $57 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $57 | $57 | $57 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $314 | $7,365 | $28,516 |
| Septoplasty CPT 30520 • ENT | $719 | $8,993 | $33,816 |