| Allergen specific IgE each allergen CPT 86003 • Allergy | $1 | $2 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $3 | $4 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $17 | $18 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $4 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $1 | $6 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $9 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $8 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $41 | $42 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $51 | $79 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $58 | $108 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $71 | $158 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $56 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $75 | $177 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $63 | $129 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $53 | $88 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $76 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $68 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $58 | $108 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $63 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $105 | $294 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $119 | $577 | $1,017 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $42 | $916 | $1,790 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $209 | $1,929 | $3,649 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,845 | $2,864 | $4,288 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $42 | $1,700 | $4,783 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $102 | $315 | $529 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $57 | $322 | $588 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $3 | $12 | $19 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $7 | $9 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $4 | $7 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $13 | $53 | $69 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $18 | $25 | $32 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $40 | $66 | $85 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $35 | $127 | $243 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $42 | $85 | $160 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $132 | $201 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $175 | $268 |
| Stress echocardiography CPT 93350 • Cardiology | $112 | $179 | $213 |
| Left and right heart catheterization CPT 93452 • Cardiology | $236 | $417 | $597 |
| Left heart catheterization CPT 93458 • Cardiology | $682 | $813 | $1,028 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $785 | $887 | $1,072 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $34 | $107 | $172 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $62 | $92 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $34 | $151 | $232 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $30 | $92 | $167 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $20 | $58 | $119 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $22 | $45 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $9 | $84 | $190 |