| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $20 | $20 | $20 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $510 | $510 | $510 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $357 | $357 | $357 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $510 | $510 | $510 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $969 | $969 | $969 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $765 | $765 | $765 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $459 | $459 | $459 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $612 | $612 | $612 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $816 | $816 | $816 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $4,202 | $6,900 | $9,606 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $6,849 | $23,826 | $32,114 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $856 | $3,052 | $4,150 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $856 | $3,327 | $4,150 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $856 | $3,052 | $4,150 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $4,049 | $4,445 | $5,298 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $4,646 | $6,286 | $8,722 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $17 | $17 | $17 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $11 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $86 | $86 | $86 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $84 | $84 | $84 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,822 | $4,175 | $8,417 |
| Left heart catheterization CPT 93458 • Cardiology | $341 | $3,879 | $8,417 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,822 | $5,018 | $8,417 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $47 | $47 | $47 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $176 | $176 | $176 |
| Unlisted dental procedure CPT 41899 • Dental | $464 | $464 | $464 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $464 | $2,574 | $4,150 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $51 | $1,549 | $4,150 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $90 | $1,522 | $4,150 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $111 | $1,809 | $4,150 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $139 | $2,304 | $4,150 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $66 | $2,596 | $4,150 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $66 | $2,208 | $4,150 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $464 | $2,921 | $4,150 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $102 | $2,217 | $4,150 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $113 | $2,298 | $4,150 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $130 | $2,224 | $4,150 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $120 | $1,868 | $4,150 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $125 | $1,779 | $4,150 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $164 | $2,311 | $4,150 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $183 | $1,660 | $4,150 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $174 | $1,928 | $4,150 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $170 | $1,886 | $4,150 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $464 | $2,921 | $4,150 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $464 | $2,048 | $4,150 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $464 | $2,048 | $4,150 |