| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $5 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $8 | $11 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $7 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $10 | $15 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $30 | $35 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $9 | $13 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $15 | $15 | $16 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $16 | $19 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $16 | $24 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $37 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $37 | $50 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $37 | $50 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $37 | $50 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $35 | $50 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $37 | $50 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $35 | $50 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $606 | $1,030 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $650 | $1,037 | $1,792 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $1,127 | $3,637 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $1,256 | $4,280 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $650 | $2,774 | $4,998 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $650 | $787 | $1,061 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $650 | $913 | $1,176 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $29 | $30 | $32 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $14 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $15 | $15 | $16 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $118 | $144 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $57 | $73 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $153 | $159 | $172 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $211 | $313 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $217 | $311 | $396 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $123 | $294 | $379 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $30 | $349 | $514 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $243 | $402 |
| Left and right heart catheterization CPT 93452 • Cardiology | $650 | $906 | $1,162 |
| Left heart catheterization CPT 93458 • Cardiology | $650 | $1,329 | $2,009 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $650 | $989 | $1,537 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $77 | $200 | $337 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $149 | $155 | $167 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $77 | $267 | $377 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $68 | $198 | $329 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $261 | $650 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $169 | $475 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $77 | $330 | $670 |