| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $5 | $10 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $7 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $6 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $9 | $12 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $19 | $30 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $10 | $20 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $9 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $17 | $32 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $9 | $16 |
| Sublingual allergen immunotherapy CPT 95199 • Allergy | $0 | $0 | $0 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $181 | $333 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $181 | $333 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $153 | $282 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $111 | $188 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $207 | $389 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $258 | $500 |
| Anesthesia for upper GI endoscopy CPT 00740 • Anesthesia | $282 | $282 | $282 |
| Anesthesia for lower GI endoscopy CPT 00810 • Anesthesia | $282 | $282 | $282 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $207 | $389 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $181 | $333 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $258 | $500 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $201 | $400 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $181 | $333 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $370 | $1,000 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $682 | $1,967 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $357 | $792 | $1,531 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $157 | $1,168 | $2,261 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $328 | $2,384 | $4,639 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,336 | $3,296 | $5,451 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,625 | $2,439 | $3,373 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $505 | $768 | $1,328 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $520 | $663 | $811 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $25 | $42 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $11 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $39 | $116 |
| Cardiovascular stress test CPT 93015 • Cardiology | $65 | $82 | $98 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $31 | $56 | $101 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $68 | $125 | $232 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $105 | $138 | $168 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $71 | $163 | $239 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $68 | $128 | $187 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $121 | $208 | $295 |
| Stress echocardiography CPT 93350 • Cardiology | $143 | $161 | $174 |
| Left and right heart catheterization CPT 93452 • Cardiology | $481 | $819 | $1,014 |
| Left heart catheterization CPT 93458 • Cardiology | $307 | $899 | $1,154 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $346 | $695 | $1,065 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $28 | $130 | $225 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $13 | $56 | $102 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $50 | $292 | $584 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $37 | $148 | $227 |