| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $9 | $9 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $21 | $21 | $21 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $13 | $13 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $137 | $137 | $137 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $170 | $170 | $170 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $139 | $139 | $139 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $1,450 | $1,450 | $1,450 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $592 | $592 | $592 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,029 | $1,029 | $1,029 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,125 | $2,125 | $2,125 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,499 | $2,499 | $2,499 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,786 | $2,786 | $2,786 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $586 | $586 | $586 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $567 | $650 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $16 | $18 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $6 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $10 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $71 | $79 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $40 | $40 | $40 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $95 | $95 | $95 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $224 | $224 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $59 | $119 | $179 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $69 | $131 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $114 | $114 | $114 |
| Stress echocardiography CPT 93350 • Cardiology | $78 | $78 | $78 |
| Left and right heart catheterization CPT 93452 • Cardiology | $635 | $635 | $635 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $513 | $774 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $758 | $1,231 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $32 | $84 | $136 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $54 | $92 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $38 | $125 | $212 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $38 | $40 | $42 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $52 | $52 | $52 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $64 | $64 | $64 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $31 | $31 | $31 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $86 | $86 | $86 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $41 | $72 | $104 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $114 | $128 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $107 | $107 | $107 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $122 | $122 | $122 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $133 | $133 | $133 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $66 | $114 | $161 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $126 | $179 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $147 | $147 | $147 |