| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $9 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $7 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $18 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $9 | $18 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $20 | $21 | $23 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $21 | $29 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $17 | $32 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $35 | $40 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $35 | $40 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $747 | $1,247 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,672 | $1,933 | $2,195 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $2,650 | $4,474 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $3,089 | $5,258 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,384 | $5,125 | $5,865 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,010 | $1,111 | $1,213 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,121 | $1,235 | $1,349 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $6 | $22 | $39 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $12 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $14 | $20 |
| Cardiovascular stress test CPT 93015 • Cardiology | $34 | $87 | $158 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $47 | $73 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $31 | $113 | $194 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $262 | $367 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $279 | $396 | $513 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $135 | $297 | $459 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $235 | $283 | $363 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $117 | $257 |
| Left and right heart catheterization CPT 93452 • Cardiology | $484 | $1,247 | $2,010 |
| Left heart catheterization CPT 93458 • Cardiology | $596 | $1,478 | $2,360 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $671 | $1,198 | $1,802 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $93 | $181 | $268 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $11 | $20 | $30 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $358 | $571 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $81 | $174 | $267 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $85 | $146 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $57 | $115 | $172 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $77 | $155 | $233 |