| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $6 | $9 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $0 | $5 | $7 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $6 | $14 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $10 | $30 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $38 | $75 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $14 | $28 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $15 | $32 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $15 | $22 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $17 | $51 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $134 | $407 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $20 | $173 | $611 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $190 | $611 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $124 | $407 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $152 | $475 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $263 | $917 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $160 | $475 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $190 | $611 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $56 | $200 | $611 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $67 | $187 | $543 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $199 | $611 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $242 | $857 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $50 | $466 | $1,682 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $431 | $2,366 | $9,857 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $759 | $5,899 | $22,647 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $294 | $1,042 | $2,336 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $303 | $831 | $1,825 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $336 | $908 | $2,027 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $436 | $1,695 | $3,928 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $484 | $2,506 | $7,875 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $12 | $36 | $62 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $18 | $30 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $18 | $31 |
| Cardiovascular stress test CPT 93015 • Cardiology | $63 | $178 | $325 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $5 | $37 | $66 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $61 | $218 | $402 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $80 | $153 | $259 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $30 | $172 | $425 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $109 | $452 | $951 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $30 | $151 | $390 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $108 | $203 |
| Left and right heart catheterization CPT 93452 • Cardiology | $195 | $1,169 | $2,200 |
| Left heart catheterization CPT 93458 • Cardiology | $287 | $1,069 | $2,200 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $275 | $1,166 | $2,200 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $31 | $266 | $731 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $10 | $145 | $310 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $191 | $490 | $929 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $120 | $172 | $284 |
| Unlisted dental procedure CPT 41899 • Dental | $79 | $79 | $79 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $13 | $285 | $795 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $19 | $290 | $795 |