| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $5 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $6 | $6 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $7 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $9 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $11 | $11 | $11 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $41 | $231 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $41 | $294 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $41 | $231 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $41 | $161 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $41 | $341 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $41 | $434 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $41 | $266 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $41 | $294 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $41 | $434 | $630 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $41 | $387 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $41 | $294 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $41 | $301 | $560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $41 | $294 | $420 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $835 | $862 | $875 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,054 | $1,261 | $1,467 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,179 | $2,594 | $3,008 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,560 | $2,887 | $3,540 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,953 | $3,953 | $3,953 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $537 | $635 | $732 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $573 | $694 | $815 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $28 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $17 | $27 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $11 | $15 |
| Cardiovascular stress test CPT 93015 • Cardiology | $99 | $150 | $175 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $49 | $89 | $108 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $116 | $183 | $251 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $101 | $152 | $177 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $216 | $293 | $371 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $125 | $165 | $205 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $317 | $431 | $488 |
| Stress echocardiography CPT 93350 • Cardiology | $291 | $296 | $307 |
| Left and right heart catheterization CPT 93452 • Cardiology | $327 | $327 | $327 |
| Left heart catheterization CPT 93458 • Cardiology | $784 | $1,037 | $1,289 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $463 | $831 | $1,198 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $147 | $160 | $172 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $11 | $104 | $197 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $219 | $227 | $235 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $136 | $159 | $183 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $18 | $52 | $69 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $22 | $42 | $62 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $90 | $97 | $105 |