| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $8 | $8 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $14 | $14 | $14 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $35 | $35 | $35 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $20 | $20 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $24 | $24 | $24 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $33 | $33 | $33 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $460 | $460 | $460 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $460 | $460 | $460 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $460 | $460 | $460 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $307 | $307 | $307 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $537 | $537 | $537 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $691 | $691 | $691 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $537 | $537 | $537 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $460 | $460 | $460 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $691 | $691 | $691 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $614 | $614 | $614 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $460 | $460 | $460 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $614 | $614 | $614 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $460 | $460 | $460 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $686 | $8,356 | $16,026 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,200 | $22,563 | $43,926 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $57 | $1,331 | $2,605 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $57 | $1,552 | $3,047 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $57 | $1,712 | $3,368 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $591 | $591 | $591 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $665 | $665 | $665 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $27 | $27 | $27 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $15 | $15 | $15 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $13 | $13 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $132 | $132 | $132 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $45 | $45 | $45 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $137 | $137 | $137 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $538 | $538 | $538 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $410 | $410 | $410 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $361 | $361 | $361 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $432 | $432 | $432 |
| Stress echocardiography CPT 93350 • Cardiology | $339 | $339 | $339 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,613 | $1,613 | $1,613 |
| Left heart catheterization CPT 93458 • Cardiology | $1,850 | $1,850 | $1,850 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,984 | $1,984 | $1,984 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $355 | $355 | $355 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $157 | $157 | $157 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $449 | $449 | $449 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $50 | $50 | $50 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $57 | $94 | $131 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $57 | $103 | $150 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $57 | $116 | $175 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $57 | $139 | $222 |