| Allergen specific IgE each allergen CPT 86003 • Allergy | $12 | $12 | $12 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $12 | $18 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $5 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $8 | $12 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $10 | $16 | $23 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $18 | $18 | $18 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $14 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $37 | $59 | $102 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $33 | $57 | $102 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $37 | $70 | $102 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $37 | $59 | $102 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $37 | $529 | $807 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,301 | $1,350 | $1,399 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,885 | $2,885 | $2,885 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $37 | $2,176 | $3,329 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,669 | $3,669 | $3,669 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $936 | $936 | $936 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $912 | $976 | $1,040 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $26 | $35 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $13 | $22 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $12 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $78 | $120 | $160 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $98 | $98 | $98 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $98 | $142 | $211 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $80 | $141 | $264 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $102 | $146 | $189 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $111 | $153 | $228 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $37 | $267 | $483 |
| Stress echocardiography CPT 93350 • Cardiology | $37 | $171 | $304 |
| Left and right heart catheterization CPT 93452 • Cardiology | $269 | $860 | $1,450 |
| Left heart catheterization CPT 93458 • Cardiology | $458 | $1,026 | $1,805 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $621 | $943 | $1,265 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $310 | $349 | $388 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $91 | $130 | $169 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $270 | $373 | $477 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $206 | $299 | $388 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $38 | $51 | $65 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $81 | $81 | $81 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $109 | $136 | $164 |