| Allergen specific IgE each allergen CPT 86003 • Allergy | $13 | $13 | $13 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $21 | $21 | $21 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $540 | $540 | $540 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $150 | $345 | $540 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $99 | $319 | $540 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $96 | $228 | $360 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $630 | $630 | $630 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $810 | $810 | $810 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $237 | $433 | $630 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $109 | $325 | $540 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $810 | $810 | $810 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $720 | $720 | $720 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $117 | $329 | $540 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $720 | $720 | $720 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $540 | $540 | $540 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $14,500 | $14,500 | $14,500 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $14,500 | $14,500 | $14,500 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $8,700 | $8,700 | $8,700 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $8,700 | $8,700 | $8,700 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $8,700 | $8,700 | $8,700 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $14,500 | $14,500 | $14,500 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $15,000 | $15,000 | $15,000 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $6 | $6 | $6 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $60 | $60 | $60 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $302 | $302 | $302 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $72 | $72 | $72 |
| Left and right heart catheterization CPT 93452 • Cardiology | $14,500 | $14,500 | $14,500 |
| Left heart catheterization CPT 93458 • Cardiology | $352 | $7,426 | $14,500 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $14,500 | $14,500 | $14,500 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $40 | $286 | $409 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $186 | $186 | $186 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $542 | $542 | $542 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $415 | $415 | $415 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $8,700 | $8,700 | $8,700 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $8,700 | $8,700 | $8,700 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $85 | $4,392 | $8,700 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $108 | $4,404 | $8,700 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $8,700 | $8,700 | $8,700 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $8,700 | $8,700 | $8,700 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $8,700 | $8,700 | $8,700 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $8,700 | $8,700 | $8,700 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $8,700 | $8,700 | $8,700 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $8,700 | $8,700 | $8,700 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $173 | $4,437 | $8,700 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $8,700 | $8,700 | $8,700 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $8,700 | $8,700 | $8,700 |