| Allergen specific IgE each allergen CPT 86003 • Allergy | $8 | $8 | $8 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $12 | $12 | $12 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $10 | $10 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $9 | $9 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $48 | $48 | $48 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $19 | $19 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $22 | $22 | $22 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $25 | $25 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $33 | $33 | $33 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $150 | $621 | $1,092 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $150 | $720 | $1,092 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $150 | $621 | $1,092 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $150 | $439 | $728 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $150 | $712 | $1,274 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $150 | $764 | $1,377 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $150 | $611 | $1,071 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $150 | $778 | $1,092 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $150 | $764 | $1,377 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $150 | $803 | $1,456 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $99 | $596 | $1,092 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $150 | $2,445 | $4,739 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $150 | $3,209 | $4,739 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,295 | $1,295 | $1,295 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $2,278 | $2,278 | $2,278 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $4,648 | $4,648 | $4,648 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $5,462 | $5,462 | $5,462 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,092 | $6,092 | $6,092 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,257 | $1,257 | $1,257 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,398 | $1,398 | $1,398 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $38 | $40 | $43 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $20 | $20 | $20 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $18 | $19 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $158 | $158 | $158 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $78 | $78 | $78 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $200 | $200 | $200 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $527 | $527 | $527 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $309 | $445 | $580 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $902 | $1,028 | $1,091 |
| Stress echocardiography CPT 93350 • Cardiology | $426 | $426 | $426 |
| Left and right heart catheterization CPT 93452 • Cardiology | $2,107 | $2,107 | $2,107 |
| Left heart catheterization CPT 93458 • Cardiology | $2,474 | $2,474 | $2,474 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $782 | $782 | $782 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $362 | $377 | $393 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $28 | $28 | $28 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $570 | $570 | $570 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $74 | $81 | $87 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $165 | $165 | $165 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $194 | $194 | $194 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $263 | $263 | $263 |