| Allergen specific IgE each allergen CPT 86003 • Allergy | $11 | $11 | $11 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $16 | $16 | $16 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $6 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $12 | $12 | $12 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $30 | $30 | $30 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $15 | $15 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $5 | $5 | $5 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $112 | $332 | $552 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $112 | $441 | $660 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $112 | $332 | $552 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $112 | $240 | $368 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $105 | $375 | $644 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $112 | $470 | $828 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $112 | $378 | $644 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $112 | $441 | $660 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $105 | $467 | $828 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $112 | $424 | $736 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $112 | $332 | $552 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $112 | $424 | $736 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $112 | $441 | $660 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $760 | $760 | $760 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,337 | $1,337 | $1,337 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,722 | $2,722 | $2,722 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,199 | $3,199 | $3,199 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,568 | $3,568 | $3,568 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $774 | $774 | $774 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $861 | $861 | $861 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $24 | $24 | $24 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $12 | $12 | $12 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $12 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $100 | $100 | $100 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $48 | $48 | $48 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $125 | $125 | $125 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $111 | $111 | $111 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $240 | $240 | $240 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $105 | $105 | $105 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $157 | $158 | $158 |
| Stress echocardiography CPT 93350 • Cardiology | $101 | $101 | $101 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,302 | $1,302 | $1,302 |
| Left heart catheterization CPT 93458 • Cardiology | $1,098 | $1,098 | $1,098 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,663 | $1,663 | $1,663 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $57 | $57 | $57 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $18 | $18 | $18 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $56 | $56 | $56 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $277 | $277 | $277 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $89 | $89 | $89 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $106 | $106 | $106 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $143 | $143 | $143 |