| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $9 | $9 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $8 | $12 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $10 | $12 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $9 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $62 | $62 | $62 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $62 | $76 | $89 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $62 | $75 | $88 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $62 | $140 | $218 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $62 | $81 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $62 | $114 | $167 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $62 | $95 | $129 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $62 | $85 | $108 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $62 | $120 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $62 | $115 | $168 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $62 | $85 | $108 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $62 | $95 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $62 | $1,140 | $2,219 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $756 | $756 | $756 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,313 | $1,313 | $1,313 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,653 | $2,653 | $2,653 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,111 | $3,111 | $3,111 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,464 | $3,464 | $3,464 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $777 | $777 | $777 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $863 | $863 | $863 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $20 | $27 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $15 | $15 | $15 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $13 | $13 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $95 | $128 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $72 | $72 | $72 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $103 | $146 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $224 | $233 | $243 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $95 | $95 | $95 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $51 | $74 | $98 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $261 | $430 |
| Stress echocardiography CPT 93350 • Cardiology | $282 | $282 | $282 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,231 | $1,231 | $1,231 |
| Left heart catheterization CPT 93458 • Cardiology | $458 | $458 | $458 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $515 | $515 | $515 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $208 | $280 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $17 | $40 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $41 | $106 | $171 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $48 | $93 | $138 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $58 | $59 | $61 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $70 | $72 | $74 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $104 | $139 |