| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| 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 | $6 | $6 | $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 antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $40 | $40 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $449 | $449 | $449 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,903 | $1,903 | $1,903 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $40 | $40 | $40 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $60 | $60 | $60 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $28 | $28 | $28 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $76 | $76 | $76 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $63 | $63 | $64 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $55 | $55 | $55 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $176 | $176 | $176 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $209 | $209 | $210 |
| Stress echocardiography CPT 93350 • Cardiology | $174 | $174 | $174 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $955 | $955 | $955 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $73 | $73 | $73 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $219 | $219 | $219 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $38 | $38 | $38 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $40 | $40 | $40 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $99 | $99 | $99 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $119 | $119 | $119 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $78 | $78 | $78 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $96 | $96 | $96 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $32 | $32 | $32 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $40 | $40 | $40 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $100 | $100 | $100 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $85 | $85 | $85 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $40 | $40 | $40 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $40 | $40 | $40 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $156 | $156 | $156 |