| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $7 | $11 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $11 | $17 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $9 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $11 | $18 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $16 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $12 | $17 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $19 | $19 | $19 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $22 | $22 | $22 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $21 | $31 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $50 | $90 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $45 | $60 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $50 | $90 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $60 | $90 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $45 | $60 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $40 | $60 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $616 | $922 | $1,228 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $30 | $1,095 | $2,160 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,211 | $3,314 | $4,417 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,595 | $3,461 | $5,192 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,792 | $5,792 | $5,792 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,203 | $1,203 | $1,203 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,338 | $1,338 | $1,338 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $25 | $37 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $11 | $18 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $13 | $19 |
| Cardiovascular stress test CPT 93015 • Cardiology | $65 | $109 | $153 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $71 | $71 | $71 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $68 | $128 | $189 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $34 | $123 | $169 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $498 | $498 | $498 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $183 | $233 | $282 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $222 | $325 | $531 |
| Stress echocardiography CPT 93350 • Cardiology | $158 | $166 | $174 |
| Left and right heart catheterization CPT 93452 • Cardiology | $219 | $1,088 | $1,958 |
| Left heart catheterization CPT 93458 • Cardiology | $990 | $1,310 | $1,631 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,065 | $1,785 | $2,504 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $88 | $88 | $88 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $76 | $128 | $180 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $226 | $383 | $539 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $77 | $126 | $175 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $36 | $49 | $62 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $158 | $158 | $158 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $213 | $213 | $213 |