| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $5 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $9 | $21 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $15 | $33 | $51 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $6 | $12 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $20 | $30 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $20 | $39 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $15 | $22 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $48 | $57 | $75 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $53 | $75 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $53 | $75 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $51 | $75 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $48 | $62 | $75 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $48 | $57 | $75 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $564 | $874 | $1,184 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,926 | $1,926 | $1,926 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $2,017 | $4,005 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,415 | $3,018 | $4,223 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,455 | $4,455 | $4,455 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,237 | $1,237 | $1,237 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $402 | $888 | $1,374 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $14 | $28 | $55 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $21 | $35 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $12 | $20 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $118 | $218 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $131 | $131 | $131 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $62 | $154 | $328 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $260 | $299 | $376 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $30 | $239 | $448 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $96 | $293 | $581 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $282 | $550 |
| Stress echocardiography CPT 93350 • Cardiology | $190 | $250 | $309 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,961 | $1,961 | $1,961 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $992 | $2,441 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,130 | $1,913 | $2,696 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $136 | $250 | $364 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $62 | $86 | $121 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $221 | $274 | $362 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $113 | $259 | $405 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $1 | $36 | $78 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $21 | $60 | $99 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $82 | $152 | $221 |