| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $7 | $11 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $9 | $17 | $21 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $8 | $9 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $12 | $16 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $14 | $21 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $7 | $20 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $21 | $31 | $50 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $21 | $31 | $50 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $21 | $31 | $50 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $21 | $31 | $50 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $21 | $28 | $50 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $50 | $50 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $448 | $492 | $612 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $778 | $858 | $1,065 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,608 | $1,837 | $2,272 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,891 | $2,084 | $2,436 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,108 | $2,342 | $2,576 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $376 | $470 | $650 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $450 | $539 | $722 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $22 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $7 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $9 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $65 | $86 | $116 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $5 | $32 | $45 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $78 | $103 | $175 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $144 | $277 | $322 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $64 | $189 | $250 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $194 | $213 | $221 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $93 | $237 | $290 |
| Stress echocardiography CPT 93350 • Cardiology | $142 | $180 | $208 |
| Left and right heart catheterization CPT 93452 • Cardiology | $232 | $664 | $981 |
| Left heart catheterization CPT 93458 • Cardiology | $278 | $737 | $1,254 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $694 | $1,018 | $1,212 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $27 | $169 | $261 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $75 | $97 | $123 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $173 | $256 | $309 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $159 | $198 | $214 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $14 | $48 | $80 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $20 | $61 | $91 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $31 | $68 | $107 |