| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $6 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $12 | $13 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $17 | $17 | $17 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $136 | $243 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $509 | $509 | $509 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $485 | $485 | $485 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $197 | $364 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $330 | $631 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $437 | $437 | $437 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $161 | $291 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $221 | $412 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $258 | $485 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $221 | $412 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $388 | $388 | $388 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $888 | $1,746 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $341 | $651 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,146 | $1,146 | $1,146 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $1,180 | $2,329 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $30 | $30 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $742 | $742 | $742 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $18 | $18 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $9 | $9 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $11 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $78 | $88 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $33 | $33 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $81 | $81 | $81 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $215 | $215 | $215 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $139 | $187 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $60 | $90 |
| Left heart catheterization CPT 93458 • Cardiology | $374 | $374 | $374 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $424 | $772 | $1,120 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $208 | $208 | $208 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $89 | $89 | $89 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $236 | $236 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $43 | $43 | $43 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $49 | $69 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $42 | $42 | $42 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $62 | $62 | $62 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $153 | $153 | $153 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $47 | $65 |