| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $6 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $6 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $7 | $11 | $15 |
| Allergy testing insect venoms CPT 95017 • Allergy | $10 | $10 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $49 | $49 | $49 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $7 | $11 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $17 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $19 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $25 | $28 | $31 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $500 | $500 | $500 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $272 | $272 | $272 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $542 | $542 | $542 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $310 | $310 | $310 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $564 | $564 | $564 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $496 | $496 | $496 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $460 | $460 | $460 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $333 | $333 | $333 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $700 | $700 | $700 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $555 | $555 | $555 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $555 | $555 | $555 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $531 | $531 | $531 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $730 | $730 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,551 | $2,212 | $2,874 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $3,117 | $4,991 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,580 | $6,444 | $10,308 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $485 | $6,303 | $12,121 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $13,514 | $13,514 | $13,514 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,782 | $1,782 | $1,782 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $817 | $1,398 | $1,978 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $23 | $32 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $17 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $20 | $28 |
| Cardiovascular stress test CPT 93015 • Cardiology | $120 | $181 | $242 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $83 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $289 | $323 | $358 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $535 | $535 | $535 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $89 | $281 | $543 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $278 | $599 | $797 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $124 | $780 | $1,053 |
| Stress echocardiography CPT 93350 • Cardiology | $156 | $460 | $764 |
| Left and right heart catheterization CPT 93452 • Cardiology | $841 | $841 | $841 |
| Left heart catheterization CPT 93458 • Cardiology | $524 | $778 | $1,033 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $815 | $1,164 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $265 | $363 | $461 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $110 | $162 | $214 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $101 | $216 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $254 | $309 | $364 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $126 | $126 | $126 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $154 | $154 | $154 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $53 | $125 | $214 |