| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $5 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $7 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $10 | $10 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $26 | $26 | $26 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $16 | $17 | $17 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $52 | $52 | $52 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $52 | $147 | $243 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $52 | $281 | $509 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $52 | $172 | $291 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $52 | $184 | $315 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $52 | $341 | $631 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $52 | $244 | $437 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $52 | $172 | $291 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $52 | $232 | $412 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $52 | $232 | $412 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $52 | $317 | $582 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $52 | $220 | $388 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $52 | $1,263 | $2,474 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $651 | $1,045 | $1,438 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,146 | $1,837 | $2,528 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $317 | $2,725 | $5,133 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $6,038 | $6,038 | $6,038 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,739 | $6,739 | $6,739 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $665 | $665 | $665 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $740 | $741 | $742 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $21 | $21 | $21 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $10 | $10 | $11 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $11 | $11 |
| Cardiovascular stress test CPT 93015 • Cardiology | $74 | $85 | $95 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $50 | $50 | $50 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $115 | $115 | $115 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $97 | $97 | $97 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $81 | $149 | $218 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $207 | $230 | $253 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $136 | $137 | $139 |
| Stress echocardiography CPT 93350 • Cardiology | $90 | $196 | $302 |
| Left and right heart catheterization CPT 93452 • Cardiology | $298 | $298 | $298 |
| Left heart catheterization CPT 93458 • Cardiology | $374 | $633 | $891 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $424 | $701 | $978 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $205 | $225 | $244 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $64 | $112 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $49 | $49 | $49 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $205 | $221 | $237 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $50 | $75 | $132 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $161 | $161 | $161 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $102 | $188 | $273 |