| Allergen specific IgE each allergen CPT 86003 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| 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 | $10 | $11 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $12 | $13 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $12 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $41 | $89 | $137 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $41 | $41 | $41 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $41 | $41 | $41 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $41 | $41 | $41 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $41 | $41 | $41 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $41 | $41 | $41 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,141 | $2,141 | $2,141 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,382 | $2,382 | $2,382 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $478 | $478 | $478 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $507 | $530 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $15 | $17 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $6 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $78 | $94 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $57 | $57 | $57 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $108 | $108 | $108 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $75 | $150 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $41 | $41 | $41 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $146 | $239 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $41 | $41 | $41 |
| Stress echocardiography CPT 93350 • Cardiology | $41 | $41 | $41 |
| Left and right heart catheterization CPT 93452 • Cardiology | $858 | $858 | $858 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $660 | $1,069 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $732 | $1,180 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $28 | $82 | $136 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $89 | $116 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $178 | $184 | $189 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $138 | $150 | $162 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $18 | $18 | $18 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $41 | $41 | $41 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $95 | $107 | $119 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $86 | $117 | $148 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $55 | $55 | $55 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $41 | $41 | $41 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $46 | $73 | $100 |