| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $6 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $7 | $15 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $18 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $12 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $17 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $8 | $17 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $10 | $19 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $195 | $496 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $102 | $272 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $231 | $602 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $172 | $425 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $175 | $564 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $388 | $1,416 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $432 | $1,204 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $317 | $1,133 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $178 | $578 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $168 | $533 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $183 | $595 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $208 | $531 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $217 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $483 | $1,678 | $2,874 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $3,117 | $4,991 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,740 | $2,963 | $4,569 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,049 | $6,014 | $12,121 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $30 | $6,772 | $13,514 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,782 | $1,782 | $1,782 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $803 | $1,112 | $1,421 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $22 | $32 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $17 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $17 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $61 | $115 | $166 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $31 | $57 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $289 | $289 | $289 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $60 | $224 | $387 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $87 | $172 | $217 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $339 | $723 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $124 | $222 | $347 |
| Stress echocardiography CPT 93350 • Cardiology | $190 | $401 | $764 |
| Left and right heart catheterization CPT 93452 • Cardiology | $2,772 | $2,772 | $2,772 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $1,267 | $2,356 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $1,267 | $2,580 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $38 | $255 | $461 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $113 | $148 | $183 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $101 | $212 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $61 | $255 | $450 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $40 | $42 | $45 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $154 | $154 | $154 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $134 | $198 | $263 |