| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $7 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $7 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $10 | $24 | $45 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $4 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $11 | $15 | $27 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $14 | $18 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $7 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $52 | $490 | $1,820 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $220 | $738 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $52 | $316 | $738 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $52 | $330 | $1,230 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $328 | $1,265 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $741 | $2,880 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $52 | $326 | $984 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $212 | $690 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $369 | $935 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $313 | $1,148 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $318 | $1,312 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $52 | $480 | $1,142 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $547 | $1,886 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $2,612 | $9,544 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $525 | $6,774 | $22,973 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $1,293 | $3,270 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $977 | $1,867 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $444 | $1,877 | $3,621 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $620 | $3,652 | $8,502 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $613 | $3,128 | $13,078 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $20 | $25 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $15 | $39 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $13 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $115 | $195 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $59 | $88 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $67 | $123 | $248 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $56 | $248 | $473 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $168 | $252 | $376 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $110 | $303 | $698 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $172 | $243 | $304 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $101 | $151 |
| Left and right heart catheterization CPT 93452 • Cardiology | $300 | $1,680 | $3,880 |
| Left heart catheterization CPT 93458 • Cardiology | $386 | $852 | $1,547 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $501 | $1,710 | $3,880 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $60 | $261 | $560 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $80 | $110 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $32 | $342 | $970 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $127 | $205 | $293 |
| Unlisted dental procedure CPT 41899 • Dental | $69 | $69 | $69 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $68 | $114 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $59 | $71 | $93 |