| Allergen specific IgE each allergen CPT 86003 • Allergy | $6 | $6 | $6 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $9 | $9 | $9 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $6 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $6 | $6 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $11 | $11 | $11 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $18 | $18 | $18 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $22 | $22 | $22 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $26 | $26 | $26 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $45 | $233 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $81 | $515 | $732 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $81 | $407 | $732 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $81 | $181 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $81 | $286 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $81 | $590 | $1,098 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $45 | $450 | $854 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $81 | $515 | $732 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $81 | $590 | $1,098 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $81 | $529 | $976 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $233 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $81 | $821 | $1,560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $81 | $411 | $732 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $816 | $816 | $816 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,438 | $1,438 | $1,438 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,909 | $2,909 | $2,909 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,413 | $3,413 | $3,413 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,788 | $3,788 | $3,788 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $813 | $813 | $813 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $905 | $905 | $905 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $24 | $24 | $24 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $11 | $11 | $11 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $13 | $13 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $123 | $123 | $123 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $67 | $67 | $67 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $126 | $126 | $126 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $459 | $459 | $459 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $97 | $97 | $97 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $109 | $109 | $109 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $236 | $236 | $236 |
| Stress echocardiography CPT 93350 • Cardiology | $320 | $320 | $320 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,537 | $1,537 | $1,537 |
| Left heart catheterization CPT 93458 • Cardiology | $454 | $454 | $454 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,395 | $1,395 | $1,395 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $333 | $333 | $333 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $145 | $145 | $145 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $59 | $59 | $59 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $52 | $52 | $52 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $125 | $125 | $125 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $34 | $34 | $34 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $174 | $174 | $174 |