| Allergen specific IgE each allergen CPT 86003 • Allergy | $1 | $4 | $6 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $1 | $5 | $9 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $6 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $7 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $17 | $30 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $9 | $16 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $14 | $18 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $2 | $13 | $21 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $5 | $16 | $29 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $45 | $133 | $300 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $45 | $133 | $300 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $55 | $218 | $300 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $45 | $115 | $200 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $55 | $252 | $350 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $99 | $333 | $450 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $55 | $252 | $350 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $45 | $133 | $300 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $45 | $198 | $450 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $55 | $285 | $400 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $133 | $300 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $55 | $285 | $400 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $55 | $218 | $300 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $48 | $754 | $1,185 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $45 | $1,065 | $2,084 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $45 | $1,489 | $4,249 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $410 | $3,246 | $4,994 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,288 | $4,227 | $5,570 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $71 | $580 | $1,088 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $262 | $775 | $1,211 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $23 | $34 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $11 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $13 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $105 | $142 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $31 | $43 | $66 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $14 | $99 | $174 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $30 | $248 | $386 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $51 | $204 | $329 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $130 | $277 | $412 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $195 | $346 | $492 |
| Stress echocardiography CPT 93350 • Cardiology | $69 | $240 | $377 |
| Left and right heart catheterization CPT 93452 • Cardiology | $459 | $1,131 | $1,803 |
| Left heart catheterization CPT 93458 • Cardiology | $815 | $1,324 | $2,117 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $905 | $1,388 | $1,644 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $148 | $274 | $393 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $26 | $71 | $120 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $38 | $296 | $499 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $33 | $158 | $313 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $4 | $71 | $138 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $45 | $48 | $54 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $63 | $76 | $89 |