| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $7 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $6 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $13 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $1 | $1 | $1 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $1 | $6 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $32 | $158 | $410 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $32 | $219 | $592 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $32 | $234 | $637 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $32 | $32 | $33 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $32 | $33 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $70 | $210 | $350 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $305 | $305 | $305 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $914 | $914 | $914 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $717 | $1,075 | $1,433 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $320 | $320 | $320 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $253 | $253 | $253 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $84 | $322 | $560 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $3 | $10 | $16 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $8 | $9 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $19 | $25 |
| Cardiovascular stress test CPT 93015 • Cardiology | $76 | $76 | $76 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $8 | $25 | $41 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $93 | $93 | $94 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $16 | $47 | $79 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $60 | $152 | $243 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $232 | $232 | $232 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $154 | $231 | $308 |
| Stress echocardiography CPT 93350 • Cardiology | $178 | $211 | $245 |
| Left and right heart catheterization CPT 93452 • Cardiology | $664 | $664 | $664 |
| Left heart catheterization CPT 93458 • Cardiology | $289 | $545 | $802 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $878 | $1,041 | $1,204 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $42 | $125 | $208 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $12 | $52 | $92 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $118 | $176 | $235 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $171 | $171 | $171 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $2 | $17 | $32 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $3 | $10 | $16 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $31 | $31 | $31 |