| 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 | $4 | $8 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $16 | $24 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $38 | $56 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $13 | $17 | $22 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $15 | $21 | $27 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $20 | $32 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $21 | $27 | $32 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $104 | $792 | $1,480 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $101 | $431 | $666 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $101 | $494 | $888 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $101 | $420 | $740 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $104 | $585 | $1,036 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $104 | $742 | $1,332 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $104 | $792 | $1,480 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $104 | $580 | $1,110 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $104 | $841 | $1,628 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $104 | $713 | $1,332 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $101 | $850 | $1,924 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $104 | $940 | $1,776 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $104 | $1,710 | $4,500 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $7,726 | $16,026 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $24,000 | $36,095 | $43,926 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $247 | $654 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $247 | $654 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $57 | $355 | $654 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $2,686 | $2,686 | $2,686 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,051 | $5,021 | $11,326 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $29 | $34 | $40 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $16 | $17 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $15 | $19 | $23 |
| Cardiovascular stress test CPT 93015 • Cardiology | $69 | $144 | $235 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $75 | $117 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $153 | $197 | $240 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $522 | $867 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $396 | $563 | $730 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $154 | $403 | $652 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $211 | $402 | $565 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $257 | $617 |
| Left and right heart catheterization CPT 93452 • Cardiology | $2,264 | $2,473 | $2,681 |
| Left heart catheterization CPT 93458 • Cardiology | $541 | $1,829 | $2,681 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $2,022 | $2,681 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $69 | $298 | $528 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $34 | $91 | $149 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $68 | $287 | $557 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $60 | $77 | $94 |
| Unlisted dental procedure CPT 41899 • Dental | $131 | $131 | $131 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $73 | $131 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $57 | $94 | $131 |