| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $6 | $8 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $8 | $8 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $15 | $15 | $15 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $15 | $15 | $15 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $7 | $9 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $10 | $10 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $45 | $45 | $45 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $328 | $683 | $1,039 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $576 | $576 | $576 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,369 | $1,369 | $1,369 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,119 | $4,119 | $4,119 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,596 | $4,596 | $4,596 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,003 | $1,003 | $1,003 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,116 | $1,144 | $1,172 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $10 | $19 | $25 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $6 | $12 | $16 |
| Cardiovascular stress test CPT 93015 • Cardiology | $132 | $136 | $139 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $24 | $24 | $24 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $63 | $63 | $63 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $48 | $48 | $48 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $166 | $311 | $456 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $163 | $297 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $151 | $184 | $218 |
| Stress echocardiography CPT 93350 • Cardiology | $116 | $116 | $116 |
| Left and right heart catheterization CPT 93452 • Cardiology | $561 | $561 | $561 |
| Left heart catheterization CPT 93458 • Cardiology | $587 | $1,243 | $1,898 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $666 | $1,057 | $1,448 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $24 | $234 | $390 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $52 | $109 | $166 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $153 | $317 | $481 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $67 | $155 | $283 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $10 | $10 | $10 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $53 | $53 | $53 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $56 | $58 | $61 |