| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $8 | $8 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $6 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $10 | $11 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $39 | $58 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $15 | $23 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $19 | $29 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $18 | $33 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $11 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $109 | $109 | $109 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $98 | $415 | $732 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $59 | $59 | $59 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $109 | $109 | $109 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $45 | $59 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $70 | $109 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $98 | $98 | $98 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $109 | $421 | $732 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $70 | $109 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $45 | $59 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $70 | $109 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $98 | $98 | $98 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $70 | $109 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $2,876 | $9,034 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $581 | $9,596 | $29,282 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $362 | $581 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $362 | $581 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $257 | $473 | $581 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $581 | $1,982 | $4,262 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $402 | $2,884 | $8,217 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $31 | $48 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $19 | $19 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $18 | $28 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $133 | $268 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $77 | $120 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $62 | $154 | $247 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $534 | $890 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $236 | $236 | $236 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $142 | $190 | $238 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $409 | $901 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $213 | $396 |
| Left and right heart catheterization CPT 93452 • Cardiology | $581 | $931 | $1,360 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $912 | $1,945 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $581 | $1,132 | $1,945 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $319 | $502 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $166 | $270 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $236 | $381 | $666 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $101 | $107 | $113 |
| Unlisted dental procedure CPT 41899 • Dental | $75 | $75 | $75 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $241 | $430 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $51 | $322 | $581 |