| 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 | $17 | $17 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $616 | $616 | $616 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,595 | $2,595 | $2,596 |
| 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 | $65 | $65 | $65 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $31 | $31 | $31 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $68 | $68 | $68 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $34 | $101 | $168 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $183 | $183 | $183 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $222 | $222 | $222 |
| Stress echocardiography CPT 93350 • Cardiology | $174 | $174 | $174 |
| Left heart catheterization CPT 93458 • Cardiology | $717 | $717 | $717 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,065 | $1,065 | $1,065 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $179 | $179 | $179 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $76 | $76 | $76 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $226 | $226 | $226 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $62 | $62 | $62 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $32 | $32 | $32 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $109 | $109 | $109 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $135 | $135 | $135 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $4 | $4 | $4 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $106 | $106 | $106 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $33 | $33 | $33 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $90 | $90 | $90 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $171 | $171 | $171 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $127 | $127 | $127 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $42 | $127 | $211 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $114 | $114 | $114 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $108 | $108 | $108 |