| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $7 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $6 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $10 | $16 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $8 | $11 | $13 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $4 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $16 | $17 | $18 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $17 | $19 | $21 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $19 | $27 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $65 | $273 | $480 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $65 | $273 | $480 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $80 | $80 | $80 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $65 | $65 | $65 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $80 | $280 | $480 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $587 | $938 | $1,290 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,022 | $3,113 | $6,044 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,181 | $3,403 | $4,625 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,339 | $3,885 | $5,430 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,473 | $4,257 | $6,040 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $622 | $2,011 | $3,928 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $691 | $3,406 | $7,875 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $22 | $27 | $31 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $13 | $16 | $18 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $14 | $18 |
| Cardiovascular stress test CPT 93015 • Cardiology | $111 | $157 | $203 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $5 | $53 | $100 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $167 | $187 | $207 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $747 | $747 | $747 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $229 | $365 | $451 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $80 | $173 | $241 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $154 | $312 | $473 |
| Stress echocardiography CPT 93350 • Cardiology | $156 | $178 | $200 |
| Left and right heart catheterization CPT 93452 • Cardiology | $665 | $1,033 | $1,768 |
| Left heart catheterization CPT 93458 • Cardiology | $366 | $1,282 | $2,957 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $412 | $1,040 | $1,768 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $34 | $58 | $83 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $22 | $55 | $118 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $69 | $149 | $296 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $39 | $143 | $328 |
| Unlisted dental procedure CPT 41899 • Dental | $131 | $131 | $131 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $34 | $66 | $120 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $39 | $86 | $173 |