| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $5 | $8 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $7 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $9 | $12 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $21 | $41 | $62 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $21 | $22 | $23 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $26 | $31 | $36 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $30 | $42 | $54 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $32 | $37 | $42 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $35 | $37 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $35 | $38 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $35 | $37 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $45 | $66 | $87 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $66 | $87 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $43 | $45 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $35 | $40 | $45 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $510 | $955 | $1,401 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $45 | $1,255 | $2,464 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $5,023 | $5,023 | $5,023 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,129 | $3,387 | $5,904 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,585 | $7,259 | $7,934 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,599 | $1,599 | $1,599 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,778 | $1,778 | $1,778 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $33 | $50 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $16 | $24 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $17 | $25 |
| Cardiovascular stress test CPT 93015 • Cardiology | $71 | $139 | $208 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $96 | $151 | $205 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $89 | $172 | $256 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $75 | $211 | $484 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $193 | $193 | $193 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $210 | $216 | $222 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $45 | $339 | $722 |
| Stress echocardiography CPT 93350 • Cardiology | $192 | $373 | $554 |
| Left and right heart catheterization CPT 93452 • Cardiology | $715 | $715 | $715 |
| Left heart catheterization CPT 93458 • Cardiology | $294 | $1,256 | $2,217 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $843 | $1,609 | $2,374 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $457 | $571 | $684 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $85 | $146 | $207 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $257 | $436 | $615 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $104 | $381 | $658 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $45 | $95 | $164 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $63 | $114 | $165 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $261 | $261 | $261 |