| 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 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $5 | $5 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $13 | $15 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $6 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $6 | $7 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $7 | $9 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $9 | $12 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $45 | $62 | $79 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $45 | $67 | $88 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $45 | $102 | $158 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $45 | $77 | $109 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $45 | $106 | $167 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $45 | $102 | $158 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $45 | $76 | $108 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $45 | $112 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $45 | $96 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $76 | $108 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $45 | $86 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $45 | $170 | $294 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $328 | $617 | $906 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $576 | $1,088 | $1,599 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,173 | $2,198 | $3,223 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,379 | $2,952 | $3,782 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,538 | $2,874 | $4,209 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $334 | $612 | $889 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $371 | $680 | $990 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $10 | $16 | $25 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $5 | $7 | $9 |
| Cardiovascular stress test CPT 93015 • Cardiology | $43 | $76 | $123 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $21 | $21 | $21 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $54 | $57 | $59 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $48 | $145 | $243 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $39 | $96 | $152 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $176 | $350 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $250 | $420 |
| Stress echocardiography CPT 93350 • Cardiology | $116 | $168 | $219 |
| Left and right heart catheterization CPT 93452 • Cardiology | $148 | $148 | $148 |
| Left heart catheterization CPT 93458 • Cardiology | $185 | $794 | $1,402 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $717 | $959 | $1,201 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $24 | $167 | $341 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $12 | $23 | $44 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $131 | $154 | $171 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $21 | $65 | $138 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $28 | $63 | $128 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $38 | $51 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $61 | $65 | $70 |