| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $12 |
| 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 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,915 | $2,915 | $2,915 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $543 | $543 | $543 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $485 | $485 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $15 | $15 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $4 | $4 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $62 | $62 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $40 | $40 | $40 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $133 | $179 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $191 | $191 | $191 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $143 | $234 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $284 | $284 | $284 |
| Left and right heart catheterization CPT 93452 • Cardiology | $273 | $273 | $273 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $587 | $923 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $629 | $973 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $40 | $91 | $142 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $62 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $178 | $178 | $178 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $138 | $138 | $138 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $66 | $66 | $66 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $75 | $75 | $75 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $70 | $70 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $41 | $76 | $93 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $100 | $100 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $66 | $66 | $66 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $73 | $73 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $222 | $222 | $222 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $1 | $3 | $6 |