| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $13 | $13 | $13 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $11 | $13 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $8 | $9 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $11 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $13 | $16 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $8 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $60 | $60 | $60 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $60 | $336 | $612 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $62 | $62 | $62 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $62 | $62 | $62 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $58 | $386 | $714 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $62 | $490 | $918 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $62 | $62 | $62 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $62 | $337 | $612 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $60 | $489 | $918 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $60 | $438 | $816 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $62 | $337 | $612 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $62 | $62 | $62 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $60 | $1,111 | $2,161 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $743 | $2,962 | $10,885 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,301 | $7,931 | $35,280 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $1,341 | $2,653 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $1,570 | $3,111 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,444 | $5,444 | $5,444 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $572 | $2,407 | $5,136 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $635 | $3,430 | $9,900 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $22 | $27 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $10 | $15 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $10 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $86 | $128 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $53 | $72 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $116 | $131 | $146 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $209 | $224 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $187 | $187 | $187 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $111 | $220 | $329 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $172 | $389 | $565 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $70 | $110 |
| Left and right heart catheterization CPT 93452 • Cardiology | $372 | $1,476 | $2,344 |
| Left heart catheterization CPT 93458 • Cardiology | $458 | $1,441 | $2,344 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $1,331 | $2,344 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $142 | $232 | $323 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $17 | $40 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $338 | $406 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $48 | $93 | $138 |
| Unlisted dental procedure CPT 41899 • Dental | $42 | $42 | $42 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $61 | $483 | $623 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $41 | $334 | $623 |