| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $8 | $8 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $6 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $5 | $5 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $10 | $10 | $10 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $10 | $11 | $11 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $13 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $15 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $19 | $20 | $20 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $80 | $307 | $564 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $80 | $309 | $564 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $65 | $301 | $564 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $80 | $207 | $376 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $80 | $381 | $658 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $80 | $548 | $885 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $65 | $313 | $658 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $80 | $308 | $564 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $80 | $503 | $846 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $80 | $437 | $752 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $80 | $371 | $564 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $80 | $503 | $1,400 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $80 | $660 | $1,200 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $695 | $695 | $695 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,225 | $1,234 | $1,243 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,497 | $2,539 | $2,580 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $485 | $1,709 | $2,933 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,262 | $3,262 | $3,262 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $740 | $740 | $740 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $817 | $821 | $824 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $19 | $21 | $22 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $11 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $11 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $100 | $110 | $120 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $46 | $49 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $102 | $102 | $102 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $366 | $366 | $366 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $89 | $199 | $310 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $140 | $177 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $270 | $336 |
| Stress echocardiography CPT 93350 • Cardiology | $99 | $131 | $163 |
| Left and right heart catheterization CPT 93452 • Cardiology | $331 | $331 | $331 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $408 | $413 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $467 | $468 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $254 | $260 | $265 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $17 | $64 | $110 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $318 | $324 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $61 | $133 | $204 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $95 | $95 | $95 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $110 | $110 | $110 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $51 | $93 | $134 |