| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $8 | $8 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $8 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $17 | $26 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $40 | $59 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $23 | $23 | $23 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $29 | $29 | $29 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $22 | $34 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $44 | $44 | $44 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $59 | $309 | $559 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $274 | $732 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $109 | $421 | $732 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $59 | $216 | $373 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $109 | $445 | $652 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $59 | $632 | $1,098 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $59 | $355 | $652 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $59 | $450 | $732 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $59 | $546 | $838 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $59 | $487 | $745 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $109 | $387 | $559 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $59 | $402 | $745 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $59 | $370 | $559 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $507 | $1,329 | $1,995 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $2,618 | $3,043 | $3,468 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,818 | $4,726 | $7,033 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,135 | $5,555 | $8,277 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,957 | $8,094 | $9,231 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,768 | $1,768 | $1,768 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,971 | $1,971 | $1,971 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $43 | $43 | $43 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $19 | $19 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $25 | $25 | $25 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $155 | $242 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $77 | $120 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $247 | $247 | $247 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $534 | $890 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $537 | $537 | $537 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $670 | $670 | $670 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $235 | $302 | $369 |
| Stress echocardiography CPT 93350 • Cardiology | $184 | $290 | $396 |
| Left and right heart catheterization CPT 93452 • Cardiology | $2,262 | $2,262 | $2,262 |
| Left heart catheterization CPT 93458 • Cardiology | $2,539 | $2,539 | $2,539 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $1,898 | $2,675 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $452 | $452 | $452 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $206 | $206 | $206 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $418 | $600 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $101 | $101 | $101 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $61 | $110 | $199 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $212 | $221 | $230 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $283 | $283 | $283 |