| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $19 | $19 | $19 |
| Allergy testing insect venoms CPT 95017 • Allergy | $22 | $22 | $22 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $58 | $58 | $58 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $25 | $25 | $25 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $29 | $29 | $29 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $95 | $126 | $158 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $95 | $95 | $95 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $65 | $65 | $65 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $924 | $1,280 | $1,637 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $66 | $1,455 | $2,845 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,322 | $4,555 | $5,787 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $6,812 | $6,812 | $6,812 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $7,598 | $7,598 | $7,598 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $769 | $790 | $810 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $855 | $878 | $900 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $28 | $38 | $49 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $17 | $17 | $17 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $12 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $123 | $123 | $124 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $76 | $76 | $76 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $144 | $200 | $257 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $92 | $92 | $92 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $183 | $183 | $183 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $241 | $288 | $335 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $415 | $465 | $514 |
| Stress echocardiography CPT 93350 • Cardiology | $304 | $492 | $680 |
| Left and right heart catheterization CPT 93452 • Cardiology | $368 | $368 | $368 |
| Left heart catheterization CPT 93458 • Cardiology | $1,704 | $2,391 | $3,079 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,525 | $1,699 | $1,873 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $257 | $357 | $457 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $215 | $237 | $259 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $119 | $428 | $737 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $103 | $209 | $315 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $59 | $97 | $134 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $72 | $119 | $165 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $58 | $170 | $282 |