| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $1 | $4 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $7 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $7 | $12 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $6 | $18 | $30 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $5 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $2 | $7 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $1 | $8 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $11 | $19 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $41 | $42 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $416 | $691 | $863 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $207 | $1,072 | $1,612 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,568 | $2,211 | $2,854 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,845 | $2,944 | $3,630 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $411 | $2,080 | $3,748 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $77 | $472 | $868 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $57 | $511 | $966 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $8 | $16 | $25 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $8 | $12 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $1 | $7 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $13 | $84 | $122 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $7 | $34 | $61 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $40 | $88 | $144 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $69 | $134 | $264 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $42 | $174 | $373 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $353 | $374 | $410 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $212 | $250 | $269 |
| Stress echocardiography CPT 93350 • Cardiology | $106 | $145 | $212 |
| Left and right heart catheterization CPT 93452 • Cardiology | $231 | $311 | $390 |
| Left heart catheterization CPT 93458 • Cardiology | $682 | $917 | $1,098 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $551 | $899 | $1,072 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $148 | $186 | $237 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $11 | $74 | $131 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $34 | $175 | $321 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $60 | $162 | $291 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $1 | $38 | $71 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $40 | $56 | $87 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $9 | $80 | $147 |