| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $7 | $13 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $12 | $20 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $9 | $15 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $12 | $20 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $32 | $51 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $10 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $17 | $28 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $20 | $32 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $17 | $31 |
| Sublingual allergen immunotherapy CPT 95199 • Allergy | $0 | $0 | $0 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $48 | $262 | $675 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $48 | $187 | $450 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $48 | $187 | $450 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $48 | $187 | $450 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $48 | $212 | $525 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $48 | $375 | $1,013 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $48 | $300 | $788 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $48 | $187 | $450 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $64 | $590 | $1,013 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $48 | $237 | $600 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $48 | $187 | $450 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $48 | $371 | $1,000 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $48 | $487 | $1,350 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $731 | $1,584 | $2,874 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $137 | $2,530 | $4,991 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,053 | $5,490 | $10,308 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,492 | $6,260 | $12,121 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $361 | $6,705 | $13,514 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $509 | $1,125 | $1,782 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $566 | $1,250 | $1,978 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $31 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $15 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $16 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $83 | $161 | $242 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $83 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $82 | $185 | $289 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $113 | $371 | $698 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $69 | $374 | $556 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $68 | $308 | $512 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $411 | $707 |
| Stress echocardiography CPT 93350 • Cardiology | $62 | $378 | $764 |
| Left and right heart catheterization CPT 93452 • Cardiology | $250 | $1,334 | $2,772 |
| Left heart catheterization CPT 93458 • Cardiology | $708 | $1,394 | $2,356 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $803 | $1,228 | $1,663 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $76 | $139 | $238 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $29 | $86 | $183 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $92 | $232 | $494 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $32 | $244 | $453 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $11 | $67 | $126 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $27 | $87 | $154 |