| Allergen specific IgE each allergen CPT 86003 • Allergy | $8 | $8 | $8 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $9 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $18 | $18 | $18 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $46 | $46 | $46 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $21 | $21 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $15 | $27 | $40 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $20 | $20 | $20 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $96 | $96 | $96 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $80 | $80 | $80 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,829 | $2,245 | $2,662 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $2,332 | $3,466 | $4,601 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $9,349 | $9,349 | $9,349 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $10,820 | $10,820 | $10,820 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $11,989 | $11,989 | $11,989 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,571 | $1,571 | $1,571 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $660 | $1,202 | $1,745 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $46 | $66 | $86 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $27 | $35 | $42 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $19 | $25 | $32 |
| Cardiovascular stress test CPT 93015 • Cardiology | $291 | $316 | $341 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $179 | $179 | $179 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $351 | $431 | $511 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $233 | $316 | $358 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $188 | $191 | $193 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $506 | $646 | $787 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $630 | $736 | $949 |
| Stress echocardiography CPT 93350 • Cardiology | $365 | $491 | $617 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,888 | $1,888 | $1,888 |
| Left heart catheterization CPT 93458 • Cardiology | $1,793 | $2,078 | $2,362 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,979 | $2,805 | $3,630 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $64 | $123 | $183 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $99 | $186 | $272 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $426 | $561 | $697 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $36 | $304 | $571 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $77 | $80 | $86 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $65 | $85 | $104 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $37 | $120 | $203 |