| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $2 | $2 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $7 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $7 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $17 | $24 | $32 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $9 | $13 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $11 | $15 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $13 | $17 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $9 | $15 | $21 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $49 | $49 | $49 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $529 | $803 | $1,078 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $916 | $1,252 | $1,588 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,860 | $2,663 | $3,210 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,163 | $3,356 | $4,479 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,402 | $3,298 | $4,194 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $509 | $728 | $947 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $566 | $808 | $1,051 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $17 | $23 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $10 | $12 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $10 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $89 | $109 | $129 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $52 | $58 | $65 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $104 | $129 | $153 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $150 | $150 | $150 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $130 | $208 | $286 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $170 | $275 | $379 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $183 | $360 | $514 |
| Stress echocardiography CPT 93350 • Cardiology | $115 | $273 | $402 |
| Left and right heart catheterization CPT 93452 • Cardiology | $552 | $795 | $1,038 |
| Left heart catheterization CPT 93458 • Cardiology | $300 | $369 | $439 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $338 | $1,160 | $1,983 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $175 | $256 | $337 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $98 | $123 | $149 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $25 | $201 | $377 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $176 | $252 | $329 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $28 | $30 | $33 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $38 | $39 | $40 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $76 | $128 | $180 |