| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $5 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $7 | $9 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $14 | $25 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $20 | $21 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $15 | $23 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $17 | $29 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $20 | $33 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $22 | $43 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $98 | $760 | $1,480 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $109 | $634 | $962 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $98 | $612 | $888 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $109 | $456 | $740 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $109 | $750 | $1,184 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $109 | $909 | $1,332 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $109 | $824 | $1,480 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $109 | $597 | $814 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $33 | $717 | $1,628 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $109 | $848 | $1,332 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $109 | $874 | $1,924 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $98 | $956 | $1,776 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $109 | $1,518 | $4,500 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $245 | $1,126 | $2,214 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $611 | $2,256 | $3,902 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $853 | $2,833 | $4,813 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $33 | $4,677 | $9,321 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $799 | $5,584 | $10,368 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $379 | $1,171 | $1,962 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $112 | $1,117 | $2,187 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $3 | $27 | $48 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $13 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $17 | $28 |
| Cardiovascular stress test CPT 93015 • Cardiology | $15 | $137 | $268 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $41 | $87 | $133 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $19 | $149 | $274 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $79 | $534 | $988 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $61 | $136 | $236 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $60 | $231 | $479 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $62 | $255 | $491 |
| Stress echocardiography CPT 93350 • Cardiology | $123 | $317 | $704 |
| Left and right heart catheterization CPT 93452 • Cardiology | $664 | $2,027 | $3,391 |
| Left heart catheterization CPT 93458 • Cardiology | $290 | $642 | $1,096 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $878 | $1,060 | $1,243 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $69 | $247 | $502 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $12 | $143 | $270 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $68 | $104 | $126 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $33 | $201 | $510 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $9 | $31 | $54 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $23 | $148 | $274 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $12 | $169 | $338 |