| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $2 | $2 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $7 | $9 |
| Allergy testing insect venoms CPT 95017 • Allergy | $10 | $10 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $8 | $8 | $8 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $14 | $17 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $9 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $60 | $222 | $384 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $38 | $161 | $384 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $60 | $222 | $384 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $60 | $158 | $256 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $60 | $254 | $448 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $60 | $318 | $576 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $60 | $254 | $448 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $60 | $276 | $384 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $60 | $318 | $576 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $60 | $286 | $512 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $60 | $222 | $384 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $60 | $286 | $512 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $60 | $276 | $384 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $591 | $703 | $790 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,377 | $1,377 | $1,377 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,907 | $2,907 | $2,907 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,343 | $3,343 | $3,343 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,669 | $3,669 | $3,669 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $648 | $648 | $648 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $720 | $720 | $720 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $19 | $22 | $24 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $9 | $12 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $9 | $10 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $79 | $98 | $112 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $69 | $69 | $69 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $124 | $141 | $159 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $192 | $192 | $192 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $75 | $75 | $75 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $86 | $158 | $229 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $126 | $126 | $126 |
| Stress echocardiography CPT 93350 • Cardiology | $187 | $187 | $187 |
| Left and right heart catheterization CPT 93452 • Cardiology | $310 | $310 | $310 |
| Left heart catheterization CPT 93458 • Cardiology | $382 | $598 | $815 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $430 | $430 | $430 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $43 | $126 | $210 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $115 | $118 | $121 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $30 | $213 | $305 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $236 | $251 | $266 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $62 | $63 | $65 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $49 | $64 | $79 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $66 | $88 | $110 |