| 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 | $6 | $6 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $15 | $15 | $15 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $11 | $11 | $11 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $45 | $45 | $45 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $583 | $583 | $583 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,028 | $1,028 | $1,028 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,446 | $2,446 | $2,446 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $15 | $15 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $75 | $75 | $75 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $76 | $76 | $76 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $276 | $276 | $276 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $208 | $208 | $208 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $252 | $252 | $252 |
| Stress echocardiography CPT 93350 • Cardiology | $197 | $197 | $197 |
| Left and right heart catheterization CPT 93452 • Cardiology | $943 | $943 | $943 |
| Left heart catheterization CPT 93458 • Cardiology | $787 | $787 | $787 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,170 | $1,170 | $1,170 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $75 | $75 | $75 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $220 | $220 | $220 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $173 | $173 | $173 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $59 | $59 | $59 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $104 | $104 | $104 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $129 | $129 | $129 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $84 | $84 | $84 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $101 | $101 | $101 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $97 | $97 | $97 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $164 | $164 | $164 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $204 | $204 | $204 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $169 | $169 | $169 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $53 | $53 | $53 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $94 | $94 | $94 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $110 | $110 | $111 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $107 | $107 | $107 |