| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $7 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $12 | $13 | $15 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $11 | $24 | $37 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $11 | $12 | $13 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $13 | $13 | $14 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $12 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $19 | $21 | $24 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $200 | $360 |
| 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 | $230 | $420 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $290 | $540 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $200 | $360 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $290 | $540 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $260 | $480 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $200 | $360 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $200 | $360 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $997 | $1,006 | $1,010 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,734 | $1,734 | $1,734 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,517 | $3,517 | $3,517 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,138 | $4,138 | $4,138 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,616 | $4,616 | $4,616 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $946 | $946 | $946 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,050 | $1,050 | $1,050 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $23 | $24 | $25 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $10 | $11 | $12 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $11 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $102 | $128 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $50 | $65 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $121 | $136 | $152 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $248 | $259 | $280 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $397 | $427 | $457 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $270 | $292 | $314 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $263 | $351 | $489 |
| Stress echocardiography CPT 93350 • Cardiology | $124 | $202 | $298 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,033 | $1,477 | $1,920 |
| Left heart catheterization CPT 93458 • Cardiology | $461 | $500 | $540 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $609 | $1,911 | $3,213 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $38 | $169 | $300 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $130 | $131 | $131 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $336 | $389 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $238 | $310 | $382 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $29 | $94 | $133 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $100 | $119 | $138 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $149 | $229 |