| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $9 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $10 | $10 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $5 | $5 | $5 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $8 | $12 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $15 | $22 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $18 | $27 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $23 | $28 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $95 | $288 | $480 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $95 | $377 | $518 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $49 | $326 | $518 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $95 | $180 | $320 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $49 | $400 | $592 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $49 | $413 | $778 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $49 | $430 | $637 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $49 | $313 | $518 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $49 | $382 | $720 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $62 | $332 | $691 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $62 | $246 | $480 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $62 | $305 | $640 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $95 | $351 | $518 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $431 | $511 | $591 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $55 | $406 | $757 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,142 | $3,530 | $4,918 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,842 | $2,292 | $2,517 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,804 | $4,553 | $6,301 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $590 | $1,007 | $1,424 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $656 | $1,033 | $1,583 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $11 | $16 | $22 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $6 | $6 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $6 | $9 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $53 | $81 | $115 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $24 | $29 | $35 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $90 | $175 | $261 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $392 | $392 | $392 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $474 | $474 | $474 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $204 | $363 | $579 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $95 | $125 | $169 |
| Stress echocardiography CPT 93350 • Cardiology | $119 | $195 | $272 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,946 | $1,946 | $1,946 |
| Left heart catheterization CPT 93458 • Cardiology | $445 | $1,213 | $2,420 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,191 | $1,462 | $1,733 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $43 | $229 | $457 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $18 | $114 | $255 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $58 | $294 | $581 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $98 | $211 | $345 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $46 | $46 | $46 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $55 | $86 | $122 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $39 | $138 | $236 |