| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $7 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $39 | $48 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $42 | $45 | $48 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $594 | $594 | $594 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,460 | $2,867 | $3,275 |
| 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 | $5 | $6 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $64 | $66 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $80 | $80 | $80 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $69 | $131 | $224 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $149 | $175 | $201 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $168 | $223 | $268 |
| Stress echocardiography CPT 93350 • Cardiology | $212 | $212 | $212 |
| Left and right heart catheterization CPT 93452 • Cardiology | $564 | $564 | $564 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $516 | $781 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $678 | $1,072 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $142 | $166 | $190 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $71 | $80 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $169 | $173 | $178 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $234 | $234 | $234 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $76 | $76 | $76 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $70 | $70 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $107 | $107 | $107 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $130 | $130 | $130 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $41 | $78 | $96 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $101 | $102 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $41 | $41 | $41 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $42 | $42 | $42 |
| 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 | $128 | $128 | $128 |