| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $11 | $11 | $11 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $8 | $8 | $8 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $9 | $11 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $15 | $18 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $19 | $23 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $11 | $19 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $46 | $273 | $500 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $46 | $165 | $283 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $46 | $294 | $542 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $46 | $129 | $212 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $46 | $235 | $425 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $46 | $466 | $885 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $46 | $253 | $460 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $46 | $223 | $400 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $46 | $312 | $578 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $46 | $395 | $743 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $46 | $321 | $595 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $46 | $283 | $521 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $46 | $388 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $620 | $620 | $620 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $990 | $1,117 | $1,243 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $413 | $1,185 | $1,956 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $620 | $1,362 | $2,104 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,224 | $2,224 | $2,224 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $619 | $619 | $619 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $687 | $752 | $817 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $29 | $30 | $31 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $18 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $11 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $109 | $122 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $61 | $79 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $191 | $191 | $191 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $94 | $94 | $94 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $254 | $282 | $311 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $278 | $300 | $323 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $124 | $213 | $302 |
| Stress echocardiography CPT 93350 • Cardiology | $97 | $132 | $167 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,084 | $1,084 | $1,084 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $877 | $1,350 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $977 | $1,490 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $228 | $247 | $265 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $99 | $106 | $113 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $257 | $294 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $48 | $135 | $222 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $25 | $25 | $25 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $51 | $51 | $51 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $53 | $129 | $214 |