| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $7 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $3 | $3 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $17 | $18 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $7 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $9 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $14 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $32 | $55 | $79 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $32 | $60 | $88 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $32 | $95 | $158 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $32 | $66 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $32 | $104 | $177 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $32 | $95 | $158 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $32 | $75 | $119 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $32 | $104 | $177 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $32 | $100 | $168 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $32 | $115 | $198 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $32 | $80 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $163 | $294 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $350 | $350 | $350 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,433 | $1,433 | $1,433 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $505 | $505 | $505 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $560 | $560 | $560 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $14 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $8 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $69 | $76 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $76 | $93 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $79 | $161 | $243 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $60 | $60 | $60 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $51 | $141 | $232 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $200 | $308 |
| Stress echocardiography CPT 93350 • Cardiology | $245 | $245 | $245 |
| Left heart catheterization CPT 93458 • Cardiology | $289 | $289 | $289 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,204 | $1,204 | $1,204 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $172 | $208 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $77 | $92 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $171 | $203 | $235 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $138 | $154 | $171 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $37 | $48 | $60 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $45 | $57 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $70 | $70 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $88 | $95 | $101 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $122 | $122 | $122 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $69 | $69 | $69 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $84 | $89 | $93 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $80 | $80 | $80 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $32 | $80 | $129 |