| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $9 | $9 | $9 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $5 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $22 | $22 | $22 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $15 | $15 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $33 | $39 | $45 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $33 | $39 | $45 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $32 | $32 | $32 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $32 | $33 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $590 | $590 | $590 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $32 | $32 | $32 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,448 | $2,448 | $2,449 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $446 | $446 | $446 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $496 | $496 | $496 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $20 | $20 | $20 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $11 | $11 | $11 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $96 | $96 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $25 | $25 | $25 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $109 | $109 | $109 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $79 | $79 | $80 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $133 | $133 | $133 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $243 | $243 | $243 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $337 | $337 | $337 |
| Stress echocardiography CPT 93350 • Cardiology | $219 | $219 | $219 |
| Left heart catheterization CPT 93458 • Cardiology | $1,087 | $1,087 | $1,087 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,200 | $1,200 | $1,200 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $31 | $31 | $31 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $116 | $116 | $116 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $190 | $190 | $190 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $27 | $27 | $27 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $37 | $41 | $45 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $76 | $76 | $76 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $119 | $119 | $119 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $144 | $144 | $144 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $63 | $63 | $63 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $84 | $84 | $84 |