| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $11 | $16 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $5 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $16 | $16 | $16 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $7 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $85 | $253 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $85 | $308 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $85 | $253 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $85 | $183 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $85 | $355 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $85 | $449 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $85 | $288 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $85 | $308 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $85 | $449 | $630 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $85 | $402 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $85 | $308 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $85 | $323 | $560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $85 | $308 | $420 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $659 | $803 | $875 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,147 | $1,147 | $1,147 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,803 | $2,131 | $2,459 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,118 | $2,322 | $2,634 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,782 | $2,782 | $2,782 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $678 | $678 | $678 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $573 | $663 | $753 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $30 | $36 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $19 | $23 | $27 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $13 | $15 |
| Cardiovascular stress test CPT 93015 • Cardiology | $120 | $157 | $175 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $34 | $72 | $108 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $182 | $216 | $251 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $182 | $192 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $80 | $168 | $257 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $87 | $106 | $125 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $167 | $381 | $488 |
| Stress echocardiography CPT 93350 • Cardiology | $93 | $225 | $291 |
| Left and right heart catheterization CPT 93452 • Cardiology | $324 | $324 | $324 |
| Left heart catheterization CPT 93458 • Cardiology | $904 | $904 | $904 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $449 | $775 | $1,100 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $140 | $187 | $235 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $128 | $163 | $197 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $36 | $129 | $222 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $264 | $264 | $264 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $32 | $52 | $69 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $22 | $43 | $64 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $31 | $82 | $133 |