| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $6 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $10 | $10 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $371 | $371 | $371 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $371 | $371 | $371 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $150 | $261 | $371 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $133 | $247 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $99 | $266 | $433 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $276 | $416 | $556 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $232 | $433 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $123 | $247 | $371 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $312 | $434 | $556 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $332 | $413 | $494 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $202 | $371 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $118 | $306 | $494 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $371 | $1,046 | $1,721 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $507 | $588 | $669 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,177 | $1,177 | $1,177 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,126 | $2,126 | $2,126 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $678 | $678 | $678 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $677 | $729 | $755 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $16 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $8 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $59 | $59 | $59 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $49 | $49 | $49 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $56 | $56 | $56 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $64 | $215 | $290 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $187 | $236 | $260 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $126 | $251 | $313 |
| Stress echocardiography CPT 93350 • Cardiology | $154 | $154 | $154 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,157 | $1,157 | $1,157 |
| Left heart catheterization CPT 93458 • Cardiology | $249 | $978 | $1,343 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $275 | $1,055 | $1,445 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $40 | $180 | $249 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $12 | $76 | $108 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $39 | $223 | $315 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $34 | $175 | $245 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $68 | $68 | $68 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $79 | $79 | $79 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $77 | $77 | $77 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $83 | $138 | $165 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $50 | $50 | $50 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $89 | $143 | $170 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $126 | $180 | $207 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $131 | $196 | $228 |