| Allergen specific IgE each allergen CPT 86003 • Allergy | $10 | $10 | $10 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $13 | $13 | $13 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $11 | $11 | $11 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $20 | $20 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $19 | $26 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $280 | $509 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $50 | $356 | $509 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $50 | $280 | $509 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $50 | $195 | $339 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $50 | $322 | $594 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $50 | $407 | $764 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $322 | $594 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $50 | $356 | $509 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $50 | $407 | $764 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $50 | $364 | $679 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $280 | $509 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $364 | $679 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $356 | $509 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $648 | $674 | $701 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,040 | $1,131 | $1,222 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,597 | $2,597 | $2,597 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,786 | $2,786 | $2,786 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,945 | $2,945 | $2,945 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $577 | $690 | $804 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $642 | $767 | $893 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $27 | $36 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $16 | $24 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $11 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $145 | $145 | $145 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $37 | $63 | $89 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $219 | $219 | $219 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $229 | $229 | $229 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $96 | $96 | $96 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $255 | $315 | $375 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $162 | $248 | $309 |
| Stress echocardiography CPT 93350 • Cardiology | $94 | $94 | $94 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,264 | $1,264 | $1,264 |
| Left heart catheterization CPT 93458 • Cardiology | $1,100 | $1,126 | $1,153 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $533 | $1,017 | $1,500 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $44 | $107 | $170 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $18 | $62 | $107 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $43 | $180 | $318 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $206 | $237 | $268 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $53 | $53 | $53 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $68 | $68 | $68 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $45 | $52 | $58 |