| 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 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $7 | $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 injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $360 | $360 | $360 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $360 | $360 | $360 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $360 | $360 | $360 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $240 | $240 | $240 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $540 | $540 | $540 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $360 | $360 | $360 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $540 | $540 | $540 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $480 | $480 | $480 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $360 | $360 | $360 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $480 | $480 | $480 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $360 | $360 | $360 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $475 | $475 | $475 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $528 | $528 | $528 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $11 | $11 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $58 | $58 | $58 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $29 | $29 | $29 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $62 | $62 | $62 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $111 | $111 | $111 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $186 | $221 | $257 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $164 | $164 | $164 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $198 | $198 | $198 |
| Stress echocardiography CPT 93350 • Cardiology | $156 | $156 | $156 |
| Left and right heart catheterization CPT 93452 • Cardiology | $770 | $770 | $770 |
| Left heart catheterization CPT 93458 • Cardiology | $883 | $883 | $883 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $949 | $949 | $949 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $188 | $188 | $188 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $80 | $80 | $80 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $238 | $238 | $238 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $184 | $184 | $184 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $137 | $137 | $137 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $171 | $171 | $171 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $137 | $137 | $137 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $167 | $167 | $167 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $158 | $158 | $158 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $217 | $217 | $217 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $343 | $343 | $343 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $160 | $160 | $160 |