| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $18 | $18 | $18 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $127 | $127 | $127 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $269 | $269 | $269 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $110 | $110 | $110 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $178 | $178 | $178 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $247 | $247 | $247 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $210 | $210 | $210 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $146 | $146 | $146 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $232 | $232 | $232 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $187 | $187 | $187 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $173 | $173 | $173 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $178 | $178 | $178 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $32 | $32 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $863 | $863 | $863 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,244 | $2,244 | $2,244 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $605 | $605 | $605 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $28 | $44 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $24 | $43 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $63 | $63 | $63 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $184 | $184 | $184 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $73 | $73 | $73 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $131 | $131 | $131 |
| Left heart catheterization CPT 93458 • Cardiology | $306 | $306 | $306 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $348 | $348 | $348 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $130 | $130 | $130 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $69 | $69 | $69 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $159 | $159 | $159 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $30 | $30 | $30 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $15 | $15 | $15 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $82 | $82 | $82 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $96 | $96 | $96 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $102 | $102 | $102 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $78 | $78 | $78 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $100 | $100 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $101 | $101 | $101 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $77 | $77 | $77 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $79 | $79 | $79 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $158 | $158 | $158 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $59 | $59 | $59 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $62 | $62 | $62 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $246 | $246 | $246 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $42 | $42 | $42 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $68 | $68 | $68 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $165 | $165 | $165 |