| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $12 | $12 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $236 | $236 | $236 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $138 | $138 | $138 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $219 | $219 | $219 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $315 | $315 | $315 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $177 | $177 | $177 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $179 | $179 | $179 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $417 | $417 | $417 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $315 | $315 | $315 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $217 | $217 | $217 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $238 | $238 | $238 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $167 | $167 | $167 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $4,754 | $8,544 | $19,913 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $4,694 | $21,001 | $53,554 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,250 | $3,833 | $4,694 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,250 | $3,833 | $4,694 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,250 | $3,546 | $4,694 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $4,754 | $5,955 | $8,356 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $528 | $6,841 | $16,885 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $63 | $63 | $63 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $65 | $65 | $65 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $102 | $102 | $102 |
| Left and right heart catheterization CPT 93452 • Cardiology | $4,694 | $6,868 | $9,520 |
| Left heart catheterization CPT 93458 • Cardiology | $264 | $5,232 | $9,520 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $6,391 | $8,738 | $9,520 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $36 | $36 | $36 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $57 | $57 | $57 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $34 | $34 | $34 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $133 | $133 | $133 |
| Unlisted dental procedure CPT 41899 • Dental | $678 | $678 | $678 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $56 | $2,371 | $4,694 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $678 | $3,355 | $4,694 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $80 | $2,536 | $4,694 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $99 | $2,541 | $4,694 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $1,137 | $3,805 | $4,694 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $678 | $3,690 | $4,694 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $97 | $2,971 | $4,694 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $85 | $2,969 | $4,694 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $678 | $3,690 | $4,694 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $1,137 | $3,064 | $4,694 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $107 | $2,381 | $4,694 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $71 | $2,649 | $4,694 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $1,137 | $3,805 | $4,694 |