| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $6 | $6 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $5 | $5 | $5 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $4 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $6 | $7 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $7 | $9 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $6 | $9 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $49 | $265 | $480 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $49 | $336 | $480 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $49 | $265 | $480 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $49 | $185 | $320 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $49 | $305 | $560 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $49 | $385 | $720 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $49 | $305 | $560 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $49 | $336 | $480 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $49 | $385 | $720 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $49 | $345 | $640 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $49 | $265 | $480 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $49 | $345 | $640 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $49 | $336 | $480 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $431 | $511 | $591 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $757 | $900 | $1,042 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,566 | $1,854 | $2,142 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,842 | $2,292 | $2,517 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $55 | $1,056 | $2,056 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $446 | $518 | $590 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $496 | $576 | $656 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $13 | $15 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $6 | $7 | $9 |
| Cardiovascular stress test CPT 93015 • Cardiology | $53 | $63 | $74 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $24 | $29 | $35 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $64 | $64 | $64 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $128 | $128 | $128 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $169 | $169 | $169 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $152 | $178 | $204 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $117 | $139 | $183 |
| Stress echocardiography CPT 93350 • Cardiology | $57 | $88 | $119 |
| Left and right heart catheterization CPT 93452 • Cardiology | $669 | $669 | $669 |
| Left heart catheterization CPT 93458 • Cardiology | $247 | $511 | $776 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $580 | $885 | $1,191 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $98 | $146 | $194 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $44 | $56 | $68 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $159 | $201 | $244 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $24 | $31 | $37 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $13 | $13 | $13 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $55 | $55 | $55 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $74 | $87 | $101 |