| Allergen specific IgE each allergen CPT 86003 • Allergy | $1 | $2 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $6 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $15 | $15 | $15 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $13 | $13 | $13 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $11 | $14 | $16 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $13 | $16 | $19 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $17 | $22 | $26 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $50 | $146 | $243 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $104 | $319 | $534 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $50 | $110 | $170 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $104 | $234 | $364 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $50 | $219 | $388 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $195 | $340 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $50 | $146 | $243 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $104 | $258 | $412 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $104 | $295 | $485 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $268 | $485 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $219 | $388 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $1,262 | $2,474 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $651 | $948 | $1,245 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,146 | $1,668 | $2,190 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $317 | $2,391 | $4,465 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $5,247 | $5,247 | $5,247 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,853 | $5,853 | $5,853 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $993 | $993 | $993 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $742 | $923 | $1,105 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $18 | $24 | $31 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $10 | $13 | $15 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $11 | $13 | $16 |
| Cardiovascular stress test CPT 93015 • Cardiology | $74 | $102 | $129 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $60 | $60 | $60 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $159 | $159 | $159 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $301 | $301 | $301 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $81 | $100 | $120 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $93 | $165 | $238 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $139 | $190 | $242 |
| Stress echocardiography CPT 93350 • Cardiology | $90 | $112 | $134 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,202 | $1,202 | $1,202 |
| Left heart catheterization CPT 93458 • Cardiology | $374 | $1,153 | $1,932 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $424 | $1,264 | $2,103 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $50 | $204 | $359 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $16 | $20 | $24 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $382 | $382 | $382 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $193 | $239 | $285 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $69 | $107 | $145 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $172 | $172 | $172 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $50 | $141 | $232 |