| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $10 | $15 |
| Allergy testing insect venoms CPT 95017 • Allergy | $20 | $20 | $20 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $49 | $49 | $49 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $11 | $15 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $17 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $17 | $21 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $25 | $28 | $31 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $265 | $500 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $271 | $752 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $165 | $300 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $134 | $238 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $297 | $564 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $270 | $510 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $236 | $442 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $109 | $267 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $345 | $659 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $23 | $289 | $555 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $293 | $555 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $270 | $510 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $263 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $710 | $1,792 | $2,874 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,237 | $2,490 | $4,991 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,543 | $5,144 | $10,308 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $620 | $4,686 | $12,121 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $13,514 | $13,514 | $13,514 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,782 | $1,782 | $1,782 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $588 | $1,128 | $1,978 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $26 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $18 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $14 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $159 | $242 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $83 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $199 | $244 | $289 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $535 | $535 | $535 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $93 | $316 | $543 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $170 | $211 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $498 | $1,053 |
| Stress echocardiography CPT 93350 • Cardiology | $97 | $431 | $764 |
| Left and right heart catheterization CPT 93452 • Cardiology | $2,772 | $2,772 | $2,772 |
| Left heart catheterization CPT 93458 • Cardiology | $295 | $1,018 | $2,356 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $1,775 | $3,744 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $39 | $190 | $461 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $30 | $74 | $110 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $39 | $288 | $494 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $48 | $247 | $453 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $31 | $71 | $126 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $24 | $89 | $154 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $53 | $177 | $263 |