| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $9 | $11 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $12 | $14 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $11 | $19 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $263 | $496 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $111 | $272 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $165 | $300 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $157 | $283 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $162 | $425 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $185 | $496 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $245 | $460 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $159 | $416 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $240 | $659 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $258 | $714 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $216 | $587 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $275 | $521 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $263 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $30 | $30 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $1,243 | $1,243 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $221 | $413 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $1,951 | $3,872 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $817 | $817 | $817 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $23 | $23 | $23 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $12 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $82 | $96 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $39 | $44 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $217 | $264 | $311 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $147 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $196 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $140 | $250 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $722 | $1,041 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $902 | $1,120 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $148 | $207 | $265 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $110 | $110 | $110 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $283 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $61 | $61 | $61 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $50 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $53 | $53 | $53 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $215 | $215 | $215 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $153 | $153 | $153 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $30 | $66 | $100 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $97 | $163 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $93 | $156 |