| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $4 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $3 | $4 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $20 | $21 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $5 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $9 | $11 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $12 | $13 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $15 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $150 | $270 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $129 | $228 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $129 | $228 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $92 | $153 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $148 | $266 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $186 | $342 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $215 | $399 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $187 | $344 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $319 | $608 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $243 | $456 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $186 | $342 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $168 | $306 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $150 | $270 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $590 | $650 | $710 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $269 | $655 | $1,041 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,107 | $3,607 | $5,106 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,473 | $3,232 | $3,991 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,755 | $4,711 | $6,667 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $483 | $709 | $934 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $538 | $578 | $619 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $24 | $35 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $12 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $8 | $9 |
| Cardiovascular stress test CPT 93015 • Cardiology | $65 | $115 | $164 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $31 | $35 | $40 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $73 | $130 | $187 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $101 | $187 | $273 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $216 | $229 | $243 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $188 | $198 | $208 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $139 | $184 | $228 |
| Stress echocardiography CPT 93350 • Cardiology | $139 | $158 | $178 |
| Left and right heart catheterization CPT 93452 • Cardiology | $443 | $666 | $889 |
| Left heart catheterization CPT 93458 • Cardiology | $308 | $669 | $1,029 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $824 | $968 | $1,112 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $185 | $301 | $417 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $75 | $77 | $79 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $40 | $137 | $235 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $181 | $304 | $426 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $21 | $41 | $60 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $69 | $70 | $72 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $89 | $91 | $93 |