| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $16 | $16 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $55 | $106 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $49 | $88 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $85 | $194 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $92 | $216 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $68 | $145 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $118 | $294 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $97 | $232 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $194 | $194 | $194 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $647 | $647 | $647 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $821 | $5,563 | $15,048 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,442 | $8,680 | $23,155 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,170 | $2,354 | $2,946 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,170 | $2,701 | $3,466 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,170 | $2,970 | $3,869 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $515 | $4,975 | $7,386 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $423 | $4,266 | $9,042 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $9 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $66 | $66 | $66 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $33 | $33 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $218 | $218 | $218 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $69 | $113 | $147 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $30 | $121 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $107 | $184 |
| Left and right heart catheterization CPT 93452 • Cardiology | $906 | $4,774 | $7,386 |
| Left heart catheterization CPT 93458 • Cardiology | $256 | $3,678 | $7,386 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $4,845 | $7,386 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $38 | $150 | $225 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $9 | $56 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $184 | $219 | $236 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $137 | $168 | $183 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $73 | $169 | $360 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $36 | $140 | $360 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $87 | $1,457 | $5,281 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $92 | $1,911 | $5,281 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $310 | $2,165 | $5,281 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $150 | $220 | $360 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $107 | $209 | $360 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $153 | $222 | $360 |