| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $18 | $18 | $18 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $371 | $371 | $371 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $127 | $249 | $371 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $269 | $320 | $371 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $129 | $247 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $178 | $305 | $433 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $247 | $401 | $556 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $224 | $433 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $146 | $259 | $371 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $232 | $394 | $556 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $187 | $341 | $494 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $191 | $371 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $178 | $336 | $494 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $201 | $371 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $507 | $588 | $669 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $863 | $1,072 | $1,177 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,244 | $2,244 | $2,244 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $678 | $678 | $678 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $605 | $705 | $755 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $7 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $63 | $63 | $63 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $49 | $49 | $49 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $184 | $254 | $290 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $73 | $198 | $260 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $131 | $253 | $313 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,157 | $1,157 | $1,157 |
| Left heart catheterization CPT 93458 • Cardiology | $306 | $997 | $1,343 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $348 | $1,079 | $1,445 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $130 | $210 | $249 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $69 | $95 | $108 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $159 | $263 | $315 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $30 | $173 | $245 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $15 | $15 | $15 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $82 | $82 | $82 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $96 | $96 | $96 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $102 | $144 | $165 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $78 | $78 | $78 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $100 | $100 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $101 | $101 | $101 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $77 | $77 | $77 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $79 | $140 | $170 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $158 | $191 | $207 |