| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $7 | $10 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $10 | $16 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $7 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $6 | $19 | $38 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $8 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $13 | $19 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $15 | $22 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $6 | $11 | $21 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $37 | $290 | $732 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $37 | $330 | $732 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $37 | $273 | $732 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $37 | $203 | $488 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $37 | $333 | $854 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $37 | $394 | $1,098 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $37 | $333 | $854 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $37 | $345 | $732 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $37 | $419 | $1,098 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $37 | $354 | $976 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $37 | $273 | $732 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $37 | $793 | $3,150 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $37 | $343 | $732 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $512 | $787 | $1,332 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $931 | $1,594 | $3,513 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $770 | $2,239 | $3,126 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,271 | $3,388 | $5,655 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $883 | $2,799 | $4,076 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $599 | $828 | $1,094 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $665 | $902 | $1,109 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $24 | $33 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $14 | $17 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $11 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $105 | $122 | $136 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $35 | $65 | $79 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $125 | $158 | $181 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $88 | $299 | $508 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $83 | $268 | $417 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $147 | $272 | $344 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $140 | $259 | $411 |
| Stress echocardiography CPT 93350 • Cardiology | $96 | $215 | $323 |
| Left and right heart catheterization CPT 93452 • Cardiology | $273 | $830 | $1,235 |
| Left heart catheterization CPT 93458 • Cardiology | $335 | $688 | $1,151 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $378 | $1,139 | $2,205 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $28 | $188 | $288 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $11 | $83 | $134 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $27 | $232 | $383 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $55 | $214 | $292 |
| Unlisted dental procedure CPT 41899 • Dental | $886 | $886 | $886 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $26 | $56 | $103 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $51 | $83 |