| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $6 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $2 | $8 | $15 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $27 | $37 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $4 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $17 | $17 | $17 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $16 | $16 | $16 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $17 | $22 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $39 | $44 | $55 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $39 | $44 | $55 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $39 | $47 | $55 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $39 | $44 | $55 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $39 | $457 | $875 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $954 | $1,237 | $1,521 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,925 | $2,620 | $3,316 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $39 | $1,973 | $3,620 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,515 | $3,276 | $4,036 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $529 | $713 | $898 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,028 | $1,028 | $1,028 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $32 | $32 | $32 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $18 | $18 | $18 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $14 | $14 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $150 | $150 | $150 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $63 | $63 | $63 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $168 | $168 | $168 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $125 | $126 | $126 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $102 | $127 | $151 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $110 | $147 | $185 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $39 | $251 | $489 |
| Stress echocardiography CPT 93350 • Cardiology | $39 | $196 | $353 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,004 | $1,004 | $1,004 |
| Left heart catheterization CPT 93458 • Cardiology | $992 | $1,358 | $1,725 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,906 | $1,906 | $1,906 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $40 | $151 | $261 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $123 | $123 | $123 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $355 | $355 | $355 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $56 | $110 | $163 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $14 | $52 | $76 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $93 | $93 | $93 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $162 | $162 | $162 |