| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $6 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $6 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $11 | $11 | $11 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $8 | $15 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $23 | $37 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $29 | $48 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $9 | $13 | $18 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $93 | $93 | $93 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $93 | $93 | $93 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $21 | $57 | $93 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $21 | $57 | $93 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $21 | $57 | $93 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $21 | $48 | $93 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $51 | $93 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $623 | $969 | $1,315 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $30 | $1,160 | $2,289 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,220 | $3,518 | $4,816 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $5,184 | $5,184 | $5,184 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,481 | $5,481 | $5,481 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $531 | $1,016 | $1,502 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $590 | $1,129 | $1,668 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $42 | $67 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $25 | $43 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $16 | $23 |
| Cardiovascular stress test CPT 93015 • Cardiology | $81 | $175 | $270 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $165 | $165 | $165 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $87 | $248 | $408 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $211 | $310 | $432 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $557 | $557 | $557 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $231 | $462 | $694 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $247 | $300 | $374 |
| Stress echocardiography CPT 93350 • Cardiology | $378 | $378 | $378 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,622 | $1,622 | $1,622 |
| Left heart catheterization CPT 93458 • Cardiology | $884 | $903 | $922 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,347 | $2,283 | $3,218 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $162 | $367 | $478 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $35 | $101 | $183 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $254 | $404 | $498 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $163 | $332 | $455 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $61 | $61 | $61 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $74 | $99 | $123 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $98 | $181 | $265 |