| Allergen specific IgE each allergen CPT 86003 • Allergy | $2 | $2 | $2 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $10 | $10 | $10 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $21 | $23 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $4 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $9 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $68 | $68 | $68 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $68 | $68 | $68 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $540 | $5,108 | $16,026 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $540 | $10,836 | $43,926 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $57 | $489 | $770 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $57 | $489 | $770 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $57 | $477 | $770 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $540 | $2,301 | $5,027 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $540 | $3,772 | $9,691 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $17 | $17 | $18 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $8 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $11 | $13 |
| Cardiovascular stress test CPT 93015 • Cardiology | $85 | $85 | $85 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $43 | $43 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $84 | $84 | $84 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $300 | $300 | $300 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $257 | $257 | $257 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $56 | $69 | $82 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $139 | $146 | $152 |
| Stress echocardiography CPT 93350 • Cardiology | $82 | $93 | $105 |
| Left and right heart catheterization CPT 93452 • Cardiology | $540 | $1,113 | $1,496 |
| Left heart catheterization CPT 93458 • Cardiology | $540 | $1,151 | $2,294 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $540 | $999 | $1,496 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $45 | $94 | $144 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $95 | $95 | $95 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $159 | $219 | $279 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $39 | $49 | $60 |
| Unlisted dental procedure CPT 41899 • Dental | $330 | $330 | $330 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $57 | $344 | $540 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $38 | $244 | $397 |