| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $2 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $2 | $5 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $10 | $15 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $4 | $4 | $4 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $5 | $5 | $5 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $6 | $9 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| Anesthesia for eye procedures CPT 00140 • 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 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 epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $264 | $386 | $507 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $74 | $74 | $74 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $133 | $976 | $1,818 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $705 | $1,420 | $2,135 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $199 | $199 | $199 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $267 | $267 | $267 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $297 | $297 | $297 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $3 | $3 | $3 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $4 | $4 | $4 |
| Cardiovascular stress test CPT 93015 • Cardiology | $37 | $53 | $69 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $20 | $26 | $33 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $37 | $37 | $37 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $134 | $156 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $114 | $114 | $114 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $102 | $102 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $54 | $144 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $61 | $123 | $184 |
| Left and right heart catheterization CPT 93452 • Cardiology | $119 | $119 | $119 |
| Left heart catheterization CPT 93458 • Cardiology | $383 | $383 | $383 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $404 | $762 | $1,120 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $19 | $19 | $19 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $37 | $37 | $37 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $125 | $180 | $236 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $17 | $17 | $17 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $5 | $38 | $70 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $64 | $64 | $64 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $78 | $78 | $78 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $36 | $36 | $36 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $121 | $137 | $153 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $26 | $63 | $100 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $40 | $80 | $119 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $55 | $80 | $105 |