| Allergen specific IgE each allergen CPT 86003 • Allergy | $11 | $11 | $11 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $17 | $17 | $17 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $7 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $14 | $14 | $14 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $35 | $35 | $35 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $10 | $12 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $17 | $19 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $21 | $24 | $27 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $12 | $20 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $75 | $75 | $75 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $75 | $75 | $75 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $756 | $800 | $845 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,228 | $1,346 | $1,464 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,985 | $2,985 | $2,985 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,500 | $3,500 | $3,500 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,896 | $3,896 | $3,896 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $814 | $814 | $814 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $560 | $732 | $904 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $31 | $34 | $37 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $18 | $18 | $18 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $13 | $13 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $149 | $149 | $149 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $89 | $89 | $89 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $170 | $170 | $170 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $119 | $119 | $119 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $340 | $340 | $340 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $105 | $169 | $232 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $170 | $293 | $354 |
| Stress echocardiography CPT 93350 • Cardiology | $154 | $246 | $339 |
| Left and right heart catheterization CPT 93452 • Cardiology | $390 | $390 | $390 |
| Left heart catheterization CPT 93458 • Cardiology | $1,091 | $1,391 | $1,692 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $540 | $540 | $540 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $41 | $225 | $410 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $162 | $162 | $162 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $242 | $358 | $474 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $223 | $296 | $369 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $77 | $77 | $77 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $91 | $91 | $91 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $81 | $117 | $152 |