| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $12 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $14 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $22 | $36 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $6 | $48 | $89 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $6 | $48 | $88 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $22 | $50 | $79 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $7 | $52 | $99 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $22 | $83 | $177 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $22 | $77 | $158 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $22 | $60 | $108 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $22 | $83 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $22 | $73 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $6 | $85 | $198 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $89 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $172 | $294 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $546 | $546 | $546 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $961 | $961 | $961 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,956 | $1,956 | $1,956 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,298 | $2,298 | $2,298 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,563 | $2,563 | $2,563 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $501 | $501 | $501 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $521 | $557 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $14 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $6 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $64 | $65 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $31 | $31 | $31 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $70 | $81 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $72 | $148 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $59 | $59 | $59 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $123 | $132 | $142 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $108 | $125 |
| Stress echocardiography CPT 93350 • Cardiology | $174 | $174 | $174 |
| Left and right heart catheterization CPT 93452 • Cardiology | $222 | $222 | $222 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $264 | $278 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $522 | $760 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $37 | $86 | $136 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $59 | $63 | $66 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $171 | $184 | $197 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $24 | $28 | $32 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $17 | $37 | $58 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $24 | $47 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $86 | $102 |