| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $9 | $14 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $42 | $42 | $42 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $12 | $16 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $16 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $18 | $27 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $18 | $22 | $27 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $540 | $540 | $540 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $127 | $333 | $540 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $269 | $404 | $540 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $110 | $235 | $360 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $178 | $404 | $630 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $247 | $528 | $810 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $210 | $420 | $630 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $146 | $343 | $540 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $232 | $521 | $810 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $187 | $454 | $720 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $173 | $356 | $540 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $178 | $449 | $720 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $286 | $540 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,101 | $1,101 | $1,101 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $863 | $1,399 | $1,936 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,244 | $3,098 | $3,953 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,651 | $4,651 | $4,651 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,192 | $5,192 | $5,192 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,129 | $1,129 | $1,129 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $605 | $931 | $1,257 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $25 | $37 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $15 | $24 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $14 | $18 |
| Cardiovascular stress test CPT 93015 • Cardiology | $63 | $111 | $158 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $184 | $335 | $486 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $73 | $271 | $469 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $131 | $320 | $510 |
| Stress echocardiography CPT 93350 • Cardiology | $494 | $494 | $494 |
| Left heart catheterization CPT 93458 • Cardiology | $306 | $1,184 | $2,061 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $348 | $1,317 | $2,286 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $130 | $272 | $414 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $69 | $125 | $181 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $159 | $344 | $529 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $30 | $216 | $403 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $15 | $57 | $98 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $82 | $101 | $121 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $96 | $128 | $160 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $102 | $152 | $202 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $244 | $244 | $244 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $78 | $140 | $201 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $100 | $174 | $248 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $101 | $153 | $205 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $77 | $156 | $235 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $79 | $167 | $255 |