| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $7 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $38 | $38 | $38 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $1 | $2 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $16 | $18 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $19 | $22 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $5 | $5 | $6 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $78 | $249 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $78 | $306 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $78 | $249 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $78 | $179 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $78 | $353 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $78 | $446 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $78 | $284 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $78 | $306 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $78 | $446 | $630 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $78 | $400 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $78 | $306 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $78 | $319 | $560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $78 | $306 | $420 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $875 | $936 | $1,057 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,836 | $1,836 | $1,836 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $36 | $1,914 | $3,791 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,458 | $4,458 | $4,458 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,970 | $4,970 | $4,970 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,059 | $1,059 | $1,059 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $573 | $874 | $1,176 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $32 | $36 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $15 | $21 | $27 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $15 | $16 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $144 | $165 | $175 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $72 | $96 | $108 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $172 | $211 | $251 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $224 | $318 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $125 | $248 | $371 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $125 | $215 | $304 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $488 | $534 | $626 |
| Stress echocardiography CPT 93350 • Cardiology | $291 | $298 | $314 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,148 | $1,148 | $1,148 |
| Left heart catheterization CPT 93458 • Cardiology | $1,235 | $1,318 | $1,400 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $2,226 | $2,226 | $2,226 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $59 | $59 | $59 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $166 | $182 | $197 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $461 | $461 | $461 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $69 | $69 | $69 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $39 | $67 | $92 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $55 | $84 | $113 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $37 | $115 | $193 |