| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $8 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $7 | $15 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $12 | $20 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $33 | $49 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $12 | $19 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $14 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $19 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $8 | $14 | $19 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $263 | $496 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $271 | $752 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $275 | $520 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $157 | $283 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $227 | $425 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $723 | $1,416 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $165 | $300 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $126 | $319 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $304 | $578 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $282 | $533 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $308 | $587 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $236 | $442 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $263 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $639 | $1,756 | $2,874 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $3,117 | $4,991 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $413 | $5,361 | $10,308 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $485 | $4,496 | $12,121 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $13,514 | $13,514 | $13,514 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,782 | $1,782 | $1,782 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $803 | $1,390 | $1,978 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $13 | $25 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $13 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $13 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $65 | $134 | $242 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $83 | $121 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $68 | $178 | $289 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $249 | $345 | $535 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $206 | $424 | $754 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $102 | $266 | $512 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $413 | $1,053 |
| Stress echocardiography CPT 93350 • Cardiology | $99 | $267 | $528 |
| Left and right heart catheterization CPT 93452 • Cardiology | $841 | $841 | $841 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $1,379 | $2,356 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $1,367 | $2,580 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $34 | $125 | $265 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $77 | $134 | $214 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $227 | $384 | $594 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $30 | $60 | $89 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $15 | $71 | $126 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $154 | $154 | $154 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $53 | $158 | $263 |