| Allergen specific IgE each allergen CPT 86003 • Allergy | $1 | $3 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $7 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $11 | $14 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $26 | $36 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $8 | $10 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $1 | $12 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $1 | $14 | $27 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $16 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $47 | $54 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $47 | $54 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $73 | $610 | $927 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $629 | $1,205 | $1,634 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,210 | $2,449 | $3,324 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $1,015 | $2,627 | $3,903 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $226 | $2,565 | $4,341 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $99 | $538 | $869 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $275 | $654 | $965 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $8 | $22 | $39 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $12 | $25 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $11 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $15 | $86 | $153 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $60 | $92 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $85 | $135 | $231 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $32 | $207 | $326 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $56 | $189 | $315 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $58 | $237 | $408 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $40 | $241 | $386 |
| Stress echocardiography CPT 93350 • Cardiology | $100 | $183 | $232 |
| Left and right heart catheterization CPT 93452 • Cardiology | $290 | $718 | $1,377 |
| Left heart catheterization CPT 93458 • Cardiology | $294 | $790 | $1,714 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $999 | $1,427 | $1,893 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $49 | $143 | $256 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $83 | $90 | $102 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $25 | $192 | $298 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $42 | $160 | $284 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $4 | $62 | $129 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $40 | $51 | $69 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $7 | $77 | $155 |