| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $6 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $13 | $22 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $6 | $25 | $52 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $11 | $20 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $17 | $25 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $19 | $30 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $19 | $39 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $62 | $93 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $60 | $101 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $77 | $108 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $114 | $218 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $74 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $97 | $167 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $96 | $158 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $62 | $101 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $100 | $177 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $93 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $80 | $108 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $86 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $70 | $128 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $639 | $985 | $1,331 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $2,345 | $2,345 | $2,345 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $4,772 | $4,772 | $4,772 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,689 | $3,660 | $5,603 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,232 | $6,232 | $6,232 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,341 | $1,341 | $1,341 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,495 | $1,495 | $1,495 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $10 | $20 | $37 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $11 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $15 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $105 | $183 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $91 | $91 | $91 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $106 | $187 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $336 | $675 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $30 | $96 | $161 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $142 | $168 | $183 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $220 | $335 |
| Stress echocardiography CPT 93350 • Cardiology | $180 | $182 | $183 |
| Left and right heart catheterization CPT 93452 • Cardiology | $852 | $1,284 | $1,716 |
| Left heart catheterization CPT 93458 • Cardiology | $1,041 | $1,483 | $1,926 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $850 | $953 | $1,057 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $39 | $189 | $391 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $117 | $210 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $171 | $338 | $617 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $87 | $125 | $149 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $42 | $57 | $72 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $58 | $70 | $83 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $84 | $99 |