| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $5 | $6 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $5 | $11 | $21 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $9 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $21 | $36 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $24 | $46 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $12 | $24 |
| Sublingual allergen immunotherapy CPT 95199 • Allergy | $0 | $0 | $0 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $6 | $224 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $6 | $224 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $6 | $190 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $6 | $155 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $6 | $258 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $6 | $276 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $6 | $219 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $6 | $190 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $6 | $131 | $405 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $6 | $293 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $6 | $190 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $6 | $533 | $1,500 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $6 | $459 | $1,348 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $357 | $581 | $738 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $152 | $1,197 | $2,343 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $392 | $3,010 | $4,803 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,519 | $3,989 | $5,641 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,577 | $2,896 | $5,003 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $509 | $540 | $599 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $566 | $732 | $1,130 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $24 | $53 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $18 | $42 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $12 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $83 | $116 | $156 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $60 | $73 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $82 | $150 | $192 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $75 | $149 | $277 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $135 | $286 | $519 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $128 | $334 | $490 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $149 | $318 | $522 |
| Stress echocardiography CPT 93350 • Cardiology | $62 | $158 | $208 |
| Left and right heart catheterization CPT 93452 • Cardiology | $285 | $581 | $858 |
| Left heart catheterization CPT 93458 • Cardiology | $351 | $765 | $1,021 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $321 | $1,032 | $2,430 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $52 | $179 | $352 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $103 | $117 | $150 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $164 | $268 | $441 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $65 | $226 | $382 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $19 | $46 | $126 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $15 | $28 | $44 |