| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $3 | $3 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $654 | $654 | $654 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $427 | $540 | $654 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $732 | $732 | $732 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $436 | $436 | $436 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $763 | $763 | $763 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $981 | $1,040 | $1,098 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $43 | $43 | $43 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $427 | $540 | $654 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $674 | $828 | $981 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $872 | $872 | $872 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $654 | $654 | $654 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $2,836 | $2,836 | $2,836 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $1,368 | $1,846 | $2,324 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $702 | $702 | $702 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $807 | $807 | $807 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,625 | $1,625 | $1,625 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,031 | $2,487 | $2,942 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $577 | $577 | $577 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $642 | $642 | $642 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $19 | $19 | $19 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $11 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $96 | $96 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $32 | $32 | $32 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $67 | $67 | $67 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $49 | $65 | $80 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $205 | $205 | $205 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $273 | $273 | $273 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $50 | $190 | $329 |
| Stress echocardiography CPT 93350 • Cardiology | $174 | $174 | $174 |
| Left and right heart catheterization CPT 93452 • Cardiology | $970 | $970 | $970 |
| Left heart catheterization CPT 93458 • Cardiology | $1,478 | $1,478 | $1,478 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,589 | $1,589 | $1,589 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $213 | $213 | $213 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $113 | $113 | $113 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $336 | $336 | $336 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $62 | $64 | $66 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $30 | $30 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $45 | $45 | $45 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $175 | $175 | $175 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $216 | $216 | $216 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $92 | $92 | $92 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $114 | $114 | $114 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $113 | $113 | $113 |