| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $7 | $10 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $1 | $8 | $15 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $8 | $14 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $8 | $14 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $5 | $10 | $14 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $7 | $13 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $1 | $7 | $15 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $1 | $13 | $21 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $17 | $26 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $50 | $53 | $60 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $50 | $53 | $60 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $50 | $53 | $60 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $50 | $53 | $60 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $50 | $53 | $60 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $69 | $108 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $69 | $108 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $102 | $521 | $939 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $136 | $1,227 | $1,893 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $272 | $2,486 | $3,823 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $319 | $2,135 | $3,951 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $237 | $2,338 | $4,406 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $190 | $734 | $1,115 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $317 | $851 | $1,237 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $9 | $19 | $28 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $1 | $7 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $5 | $10 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $23 | $70 | $116 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $23 | $53 | $80 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $145 | $145 | $145 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $89 | $109 | $129 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $109 | $208 | $383 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $121 | $128 | $132 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $191 | $224 |
| Stress echocardiography CPT 93350 • Cardiology | $25 | $169 | $312 |
| Left and right heart catheterization CPT 93452 • Cardiology | $616 | $1,062 | $1,508 |
| Left heart catheterization CPT 93458 • Cardiology | $181 | $711 | $1,770 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $569 | $966 | $1,362 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $121 | $253 | $328 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $9 | $74 | $140 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $29 | $191 | $353 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $122 | $222 | $321 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $33 | $67 | $110 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $13 | $72 | $130 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $60 | $65 | $69 |