| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $6 | $15 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $6 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $10 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $35 | $39 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $44 | $79 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $52 | $88 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $76 | $158 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $50 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $69 | $177 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $66 | $129 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $52 | $108 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $69 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $62 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $52 | $108 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $66 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $98 | $294 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $342 | $507 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $848 | $848 | $848 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $889 | $1,748 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $1,394 | $2,135 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $30 | $1,127 | $2,224 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $567 | $567 | $567 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $630 | $630 | $630 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $9 | $15 | $21 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $9 | $13 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $74 | $97 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $46 | $59 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $86 | $128 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $160 | $189 | $243 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $30 | $117 | $205 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $142 | $174 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $213 | $293 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $96 | $183 |
| Left and right heart catheterization CPT 93452 • Cardiology | $607 | $756 | $905 |
| Left heart catheterization CPT 93458 • Cardiology | $760 | $900 | $1,041 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $1,150 | $1,209 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $171 | $207 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $59 | $80 | $102 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $171 | $226 | $262 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $33 | $140 | $203 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $43 | $60 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $50 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $41 | $70 | $99 |