| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $2 | $2 | $2 |
| Allergy testing insect venoms CPT 95017 • Allergy | $2 | $2 | $2 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $4 | $4 | $4 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $1 | $1 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $5 | $5 | $5 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $8 | $8 | $8 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $377 | $377 | $377 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $493 | $493 | $493 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $166 | $166 | $166 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $65 | $65 | $65 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $600 | $600 | $600 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $179 | $179 | $179 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,864 | $1,864 | $1,864 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $267 | $267 | $267 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $297 | $297 | $297 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $3 | $3 | $3 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $4 | $4 | $4 |
| Cardiovascular stress test CPT 93015 • Cardiology | $37 | $37 | $37 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $20 | $20 | $20 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $37 | $37 | $37 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $134 | $134 | $134 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $31 | $31 | $31 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $35 | $35 | $35 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $122 | $122 | $122 |
| Stress echocardiography CPT 93350 • Cardiology | $96 | $96 | $96 |
| Left and right heart catheterization CPT 93452 • Cardiology | $339 | $339 | $339 |
| Left heart catheterization CPT 93458 • Cardiology | $532 | $532 | $532 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $168 | $168 | $168 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $79 | $79 | $79 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $37 | $37 | $37 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $19 | $19 | $19 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $97 | $97 | $97 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $23 | $23 | $23 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $7 | $7 | $7 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $29 | $29 | $29 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $36 | $36 | $36 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $44 | $44 | $44 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $26 | $26 | $26 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $26 | $26 | $26 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $55 | $55 | $55 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $35 | $35 | $35 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $42 | $42 | $42 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $35 | $35 | $35 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $91 | $91 | $91 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $75 | $75 | $75 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $154 | $154 | $154 |