| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $9 | $16 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $15 | $28 | $42 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $4 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $6 | $13 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $7 | $15 | $23 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $6 | $10 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $85 | $253 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $82 | $307 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $95 | $258 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $85 | $183 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $95 | $359 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $82 | $448 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $82 | $286 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $45 | $188 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $82 | $448 | $630 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $95 | $405 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $95 | $312 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $82 | $321 | $560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $82 | $307 | $420 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $875 | $975 | $1,174 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,944 | $1,944 | $1,944 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,815 | $2,695 | $3,576 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,634 | $3,857 | $4,468 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,233 | $5,233 | $5,233 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,089 | $1,089 | $1,089 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $545 | $869 | $1,194 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $33 | $37 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $17 | $22 | $27 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $15 | $16 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $120 | $157 | $175 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $23 | $68 | $108 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $137 | $194 | $251 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $281 | $490 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $312 | $342 | $371 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $125 | $194 | $263 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $250 | $396 | $488 |
| Stress echocardiography CPT 93350 • Cardiology | $291 | $314 | $360 |
| Left and right heart catheterization CPT 93452 • Cardiology | $477 | $477 | $477 |
| Left heart catheterization CPT 93458 • Cardiology | $271 | $335 | $399 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,477 | $1,784 | $2,091 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $28 | $210 | $393 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $22 | $110 | $197 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $410 | $433 | $456 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $42 | $181 | $319 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $39 | $96 | $138 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $48 | $67 | $85 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $28 | $81 | $133 |