| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $9 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $507 | $507 | $507 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $895 | $895 | $895 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,818 | $1,818 | $1,818 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,135 | $2,135 | $2,135 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,377 | $2,377 | $2,377 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $514 | $514 | $514 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $572 | $572 | $572 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $68 | $68 | $68 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $33 | $33 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $72 | $72 | $72 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $61 | $139 | $217 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $124 | $124 | $124 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $234 | $234 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $183 | $183 | $183 |
| Left and right heart catheterization CPT 93452 • Cardiology | $905 | $905 | $905 |
| Left heart catheterization CPT 93458 • Cardiology | $286 | $664 | $1,041 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $1,120 | $1,120 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $148 | $167 | $186 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $79 | $79 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $235 | $235 | $235 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $33 | $108 | $183 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $15 | $43 | $70 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $80 | $80 | $80 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $99 | $99 | $99 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $123 | $123 | $123 |