| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $11 | $11 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $23 | $23 | $23 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $22 | $22 | $22 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $25 | $25 | $25 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $23 | $26 | $28 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $9 | $9 | $9 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $23 | $43 | $77 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $23 | $50 | $77 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $23 | $43 | $77 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $23 | $49 | $75 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $53 | $75 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $54 | $77 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $45 | $75 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $710 | $1,091 | $1,473 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,247 | $1,920 | $2,592 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,543 | $3,876 | $5,209 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,003 | $4,070 | $6,206 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,922 | $6,922 | $6,922 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,505 | $1,505 | $1,505 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $588 | $1,131 | $1,673 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $23 | $32 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $16 | $18 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $13 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $140 | $169 | $197 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $90 | $90 | $90 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $199 | $221 | $242 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $467 | $467 | $467 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $81 | $119 | $157 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $197 | $240 | $282 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $318 | $366 | $391 |
| Stress echocardiography CPT 93350 • Cardiology | $524 | $524 | $524 |
| Left and right heart catheterization CPT 93452 • Cardiology | $2,495 | $2,495 | $2,495 |
| Left heart catheterization CPT 93458 • Cardiology | $744 | $1,836 | $2,929 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $954 | $1,036 | $1,118 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $151 | $348 | $544 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $81 | $138 | $195 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $39 | $75 | $112 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $194 | $313 | $432 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $31 | $86 | $173 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $24 | $114 | $204 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $275 | $275 | $275 |