| Allergen specific IgE each allergen CPT 86003 • Allergy | $14 | $14 | $14 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $21 | $21 | $21 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $13 | $18 | $23 |
| Allergy testing insect venoms CPT 95017 • Allergy | $24 | $34 | $44 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $60 | $60 | $60 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $24 | $24 | $24 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $27 | $27 | $27 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $31 | $31 | $31 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $9 | $9 | $9 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $105 | $105 | $105 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $60 | $83 | $107 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $105 | $105 | $105 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $107 | $495 | $883 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $107 | $107 | $107 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $107 | $1,645 | $3,183 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $2,368 | $2,368 | $2,368 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $3,496 | $3,496 | $3,496 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $8,495 | $8,495 | $8,495 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $6,785 | $8,384 | $9,982 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $11,134 | $11,134 | $11,134 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $3,324 | $3,324 | $3,324 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $3,419 | $3,419 | $3,419 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $69 | $69 | $69 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $36 | $36 | $36 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $33 | $33 | $33 |
| Cardiovascular stress test CPT 93015 • Cardiology | $386 | $386 | $386 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $190 | $190 | $190 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $489 | $489 | $489 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $1,462 | $1,477 | $1,492 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $336 | $336 | $336 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $372 | $372 | $372 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $1,346 | $1,360 | $1,374 |
| Stress echocardiography CPT 93350 • Cardiology | $374 | $374 | $374 |
| Left and right heart catheterization CPT 93452 • Cardiology | $3,805 | $3,805 | $3,805 |
| Left heart catheterization CPT 93458 • Cardiology | $0 | $0 | $0 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $6,582 | $6,582 | $6,582 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $809 | $809 | $809 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $51 | $51 | $51 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $153 | $153 | $153 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $115 | $115 | $115 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $185 | $190 | $194 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $218 | $218 | $218 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $296 | $296 | $296 |