| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $16 | $16 | $16 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $31 | $31 | $31 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $48 | $48 | $48 |
| 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 | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $44 | $48 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,096 | $1,096 | $1,096 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,903 | $3,269 | $4,634 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $24 | $24 | $24 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $9 | $9 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $14 | $14 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $121 | $121 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $125 | $125 | $125 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $21 | $165 | $309 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $30 | $30 | $30 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $336 | $336 | $336 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $210 | $310 | $411 |
| Stress echocardiography CPT 93350 • Cardiology | $320 | $320 | $320 |
| Left heart catheterization CPT 93458 • Cardiology | $299 | $299 | $299 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,932 | $1,932 | $1,932 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $35 | $35 | $35 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $146 | $146 | $146 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $436 | $436 | $436 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $65 | $65 | $65 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $38 | $38 | $38 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $114 | $114 | $114 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $176 | $176 | $176 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $217 | $217 | $217 |
| 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 | $170 | $170 | $170 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $277 | $277 | $277 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $201 | $272 | $342 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $178 | $178 | $178 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |