| Allergen specific IgE each allergen CPT 86003 • Allergy | $1 | $1 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $2 | $2 | $2 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $7 | $13 | $20 |
| 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 | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $15 | $15 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $44 | $613 | $1,752 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $44 | $503 | $1,420 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $44 | $565 | $1,606 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $44 | $905 | $2,628 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $44 | $881 | $2,556 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $44 | $467 | $1,314 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $44 | $857 | $2,482 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $44 | $834 | $2,414 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $44 | $645 | $1,846 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $44 | $597 | $1,704 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $44 | $321 | $876 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $467 | $618 | $769 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $770 | $770 | $770 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,648 | $1,648 | $1,648 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,578 | $2,578 | $2,578 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $574 | $574 | $574 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $74 | $283 | $493 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $110 | $446 | $782 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $20 | $26 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $8 | $10 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $4 | $4 | $4 |
| Cardiovascular stress test CPT 93015 • Cardiology | $72 | $72 | $72 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $7 | $7 | $7 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $16 | $16 | $16 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $139 | $139 | $139 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $47 | $73 | $100 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $68 | $131 | $206 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $106 | $146 | $186 |
| Stress echocardiography CPT 93350 • Cardiology | $111 | $119 | $127 |
| Left and right heart catheterization CPT 93452 • Cardiology | $222 | $474 | $727 |
| Left heart catheterization CPT 93458 • Cardiology | $488 | $661 | $833 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $522 | $858 | $1,193 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $40 | $53 | $65 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $17 | $19 | $20 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $256 | $256 | $256 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $56 | $127 | $198 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $1 | $23 | $44 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $39 | $39 | $39 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $33 | $65 | $96 |