| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $35 | $35 | $35 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $559 | $559 | $559 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,019 | $2,019 | $2,019 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,371 | $2,371 | $2,371 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $468 | $468 | $468 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $520 | $520 | $520 |
| Cardiovascular stress test CPT 93015 • Cardiology | $68 | $68 | $68 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $35 | $35 | $35 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $248 | $248 | $248 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $180 | $180 | $180 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $217 | $217 | $217 |
| Stress echocardiography CPT 93350 • Cardiology | $170 | $170 | $170 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $991 | $991 | $991 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $215 | $215 | $215 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $1 | $1 | $1 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $19 | $19 | $19 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $85 | $85 | $85 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $132 | $132 | $132 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $6 | $45 | $85 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $103 | $103 | $103 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $89 | $89 | $89 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $98 | $98 | $98 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $110 | $110 | $110 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $134 | $134 | $134 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $148 | $148 | $148 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $123 | $123 | $123 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $170 | $170 | $170 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $197 | $197 | $197 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $212 | $212 | $212 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $43 | $68 | $92 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $59 | $59 | $59 |