| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $6 | $9 |
| Allergy testing insect venoms CPT 95017 • Allergy | $13 | $13 | $13 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $11 | $11 | $11 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $7 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $15 | $21 | $23 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $13 | $17 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $8 | $15 | $23 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $40 | $40 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $507 | $1,019 | $1,373 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $30 | $1,508 | $2,420 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,818 | $3,684 | $5,012 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,956 | $5,420 | $5,885 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,512 | $5,971 | $6,431 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $791 | $791 | $791 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $573 | $944 | $1,377 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $22 | $30 | $35 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $10 | $15 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $10 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $108 | $149 | $169 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $54 | $54 | $54 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $72 | $118 | $172 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $398 | $547 | $622 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $218 | $257 | $336 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $193 | $376 | $468 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $198 | $358 | $567 |
| Stress echocardiography CPT 93350 • Cardiology | $106 | $106 | $106 |
| Left and right heart catheterization CPT 93452 • Cardiology | $355 | $355 | $355 |
| Left heart catheterization CPT 93458 • Cardiology | $690 | $1,200 | $1,774 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $1,656 | $2,652 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $38 | $121 | $231 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $105 | $155 | $194 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $58 | $287 | $569 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $80 | $227 | $366 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $16 | $74 | $164 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $22 | $98 | $220 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $37 | $124 | $233 |