| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $4 | $6 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $6 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $7 | $10 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $6 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $12 | $23 | $35 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $7 | $23 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $14 | $17 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $16 | $21 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $5 | $13 | $21 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $48 | $66 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $66 | $66 | $66 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,060 | $1,341 | $1,545 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $30 | $970 | $1,909 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,693 | $4,909 | $5,577 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $2,394 | $4,758 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $30 | $2,406 | $4,783 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $514 | $781 | $875 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $963 | $1,253 | $1,740 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $8 | $20 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $14 | $18 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $13 | $19 | $27 |
| Cardiovascular stress test CPT 93015 • Cardiology | $68 | $111 | $128 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $62 | $77 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $72 | $116 | $149 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $301 | $425 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $103 | $210 | $308 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $140 | $371 | $621 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $181 | $492 | $760 |
| Stress echocardiography CPT 93350 • Cardiology | $115 | $321 | $586 |
| Left and right heart catheterization CPT 93452 • Cardiology | $409 | $795 | $1,428 |
| Left heart catheterization CPT 93458 • Cardiology | $503 | $1,551 | $3,151 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $690 | $2,235 | $3,393 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $242 | $425 | $592 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $20 | $139 | $259 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $232 | $487 | $742 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $250 | $388 | $576 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $55 | $162 | $220 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $66 | $189 | $255 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $114 | $238 | $300 |