| Allergen specific IgE each allergen CPT 86003 • Allergy | $10 | $10 | $10 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $10 | $16 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $12 | $16 |
| Allergy testing insect venoms CPT 95017 • Allergy | $16 | $27 | $34 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $21 | $24 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $18 | $29 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $18 | $28 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $24 | $38 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $11 | $18 | $25 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $60 | $76 | $110 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $60 | $76 | $110 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $60 | $82 | $105 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $42 | $76 | $110 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $42 | $70 | $110 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $594 | $1,651 | $2,707 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $4,761 | $4,761 | $4,761 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $8,626 | $9,170 | $9,714 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,460 | $8,004 | $11,415 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $42 | $6,387 | $12,731 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $3,293 | $3,293 | $3,293 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $3,613 | $3,613 | $3,613 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $15 | $45 | $75 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $23 | $39 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $21 | $36 |
| Cardiovascular stress test CPT 93015 • Cardiology | $66 | $237 | $408 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $201 | $238 | $275 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $80 | $298 | $516 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $69 | $1,240 | $2,107 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $387 | $387 | $387 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $201 | $842 | $1,484 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $268 | $1,128 | $1,940 |
| Stress echocardiography CPT 93350 • Cardiology | $212 | $657 | $1,102 |
| Left and right heart catheterization CPT 93452 • Cardiology | $5,444 | $5,444 | $5,444 |
| Left heart catheterization CPT 93458 • Cardiology | $3,327 | $6,022 | $8,717 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,072 | $4,014 | $6,956 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $657 | $772 | $887 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $80 | $202 | $324 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $166 | $168 | $169 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $136 | $142 | $148 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $42 | $94 | $196 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $64 | $68 | $71 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $108 | $211 | $314 |