| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $14 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $37 | $44 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $37 | $44 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $37 | $44 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $37 | $44 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $37 | $44 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $37 | $44 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $623 | $623 | $623 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,198 | $2,198 | $2,198 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,578 | $2,578 | $2,578 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,377 | $2,377 | $2,377 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $493 | $493 | $493 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $68 | $70 | $72 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $37 | $37 | $37 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $72 | $72 | $72 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $139 | $158 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $156 | $156 | $156 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $206 | $206 | $206 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $247 | $247 | $247 |
| Stress echocardiography CPT 93350 • Cardiology | $183 | $189 | $196 |
| Left and right heart catheterization CPT 93452 • Cardiology | $675 | $675 | $675 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,193 | $1,193 | $1,193 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $163 | $163 | $163 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $79 | $79 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $255 | $255 | $256 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $149 | $149 | $149 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $68 | $68 | $68 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $78 | $78 | $78 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $148 | $148 | $148 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $97 | $97 | $97 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $115 | $115 | $115 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $101 | $101 | $101 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $110 | $110 | $110 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $120 | $120 | $120 |