| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $4 | $6 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $5 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $7 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $16 | $23 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $5 | $9 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $11 | $14 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $14 | $20 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $8 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $150 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $109 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $135 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $102 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $151 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $182 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $151 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $122 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $189 | $630 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $168 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $154 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $154 | $560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $141 | $420 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $554 | $616 | $731 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $975 | $1,061 | $1,250 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $360 | $1,735 | $2,344 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $423 | $2,095 | $2,519 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,114 | $2,533 | $2,648 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $526 | $557 | $599 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $583 | $626 | $665 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $22 | $28 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $11 | $18 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $10 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $74 | $96 | $112 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $35 | $52 | $68 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $73 | $111 | $169 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $83 | $114 | $173 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $45 | $183 | $237 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $79 | $229 | $314 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $118 | $292 | $363 |
| Stress echocardiography CPT 93350 • Cardiology | $72 | $154 | $236 |
| Left and right heart catheterization CPT 93452 • Cardiology | $247 | $438 | $944 |
| Left heart catheterization CPT 93458 • Cardiology | $318 | $848 | $1,176 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $395 | $969 | $1,298 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $31 | $150 | $238 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $13 | $87 | $127 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $42 | $201 | $267 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $37 | $177 | $231 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $17 | $40 | $58 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $27 | $47 | $70 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $40 | $44 | $52 |