| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $9 | $15 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $12 | $18 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $35 | $40 | $47 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $14 | $16 | $18 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $11 | $14 | $16 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $13 | $19 | $26 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $18 | $24 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $149 | $378 | $606 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $39 | $296 | $606 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $142 | $387 | $606 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $149 | $257 | $404 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $142 | $443 | $707 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $149 | $618 | $909 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $142 | $655 | $1,116 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $149 | $389 | $606 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $39 | $344 | $783 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $39 | $322 | $696 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $142 | $390 | $606 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $149 | $416 | $808 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $149 | $756 | $1,746 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $651 | $993 | $1,237 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,146 | $1,791 | $2,174 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,329 | $3,270 | $4,242 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,987 | $5,144 | $5,223 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,560 | $5,560 | $5,560 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $469 | $753 | $1,038 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $742 | $947 | $1,152 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $30 | $42 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $10 | $17 | $27 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $14 | $16 |
| Cardiovascular stress test CPT 93015 • Cardiology | $88 | $138 | $178 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $71 | $71 | $71 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $168 | $168 | $168 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $148 | $230 | $312 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $42 | $146 | $316 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $123 | $288 | $526 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $139 | $371 | $573 |
| Stress echocardiography CPT 93350 • Cardiology | $90 | $339 | $555 |
| Left and right heart catheterization CPT 93452 • Cardiology | $490 | $490 | $490 |
| Left heart catheterization CPT 93458 • Cardiology | $374 | $1,354 | $2,315 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $424 | $1,591 | $2,567 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $143 | $214 | $292 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $127 | $203 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $375 | $467 | $594 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $43 | $149 | $344 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $37 | $82 | $110 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $21 | $74 | $127 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $35 | $118 | $216 |