| 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 head and neck procedures CPT 00300 • Anesthesia | $30 | $68 | $106 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $59 | $88 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $112 | $194 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $123 | $216 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $88 | $145 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $162 | $294 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $131 | $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 | $7,934 | $15,048 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,442 | $12,299 | $23,155 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,170 | $2,058 | $2,946 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,170 | $2,318 | $3,466 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,170 | $2,520 | $3,869 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $515 | $3,770 | $7,025 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $423 | $2,674 | $7,025 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $10 | $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 | $125 | $182 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $97 | $166 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $184 | $184 | $184 |
| Left and right heart catheterization CPT 93452 • Cardiology | $906 | $3,467 | $6,029 |
| Left heart catheterization CPT 93458 • Cardiology | $256 | $2,442 | $6,029 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $3,575 | $6,029 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $187 | $206 | $225 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $9 | $44 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $184 | $210 | $236 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $137 | $160 | $183 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $73 | $217 | $360 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $36 | $157 | $360 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $87 | $182 | $360 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $92 | $226 | $360 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $310 | $607 | $903 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $150 | $255 | $360 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $107 | $217 | $360 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $153 | $256 | $360 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $175 | $268 | $360 |