| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $7 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $7 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $22 | $22 | $22 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $1 | $1 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $16 | $16 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $52 | $52 | $52 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,210 | $1,210 | $1,210 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,918 | $2,918 | $2,918 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $18 | $18 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $90 | $90 | $90 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $44 | $44 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $92 | $92 | $92 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $331 | $331 | $331 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $280 | $280 | $280 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $160 | $160 | $160 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $304 | $304 | $304 |
| Stress echocardiography CPT 93350 • Cardiology | $147 | $147 | $147 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,149 | $1,149 | $1,149 |
| Left heart catheterization CPT 93458 • Cardiology | $386 | $386 | $386 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $992 | $992 | $992 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $215 | $215 | $215 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $92 | $92 | $92 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $226 | $226 | $226 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $173 | $173 | $173 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $81 | $81 | $81 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $143 | $143 | $143 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $177 | $177 | $177 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $116 | $116 | $116 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $139 | $139 | $139 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $146 | $146 | $146 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $179 | $179 | $179 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $134 | $134 | $134 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $282 | $282 | $282 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $14 | $14 | $14 |