| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $8 | $8 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $7 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $25 | $25 | $25 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $58 | $58 | $58 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $3 | $5 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $19 | $29 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $22 | $33 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $11 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $109 | $421 | $732 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $109 | $524 | $732 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $98 | $415 | $732 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $109 | $299 | $488 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $98 | $476 | $854 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $98 | $598 | $1,098 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $98 | $476 | $854 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $109 | $524 | $732 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $98 | $598 | $1,098 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $109 | $543 | $976 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $109 | $421 | $732 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $98 | $537 | $976 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $109 | $524 | $732 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $2,214 | $2,214 | $2,214 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $3,902 | $3,902 | $3,902 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $4,813 | $4,813 | $4,813 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $9,321 | $9,321 | $9,321 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $10,368 | $10,368 | $10,368 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,962 | $1,962 | $1,962 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $485 | $1,336 | $2,187 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $10 | $29 | $48 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $4 | $13 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $18 | $28 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $165 | $268 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $133 | $133 | $133 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $274 | $274 | $274 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $224 | $606 | $988 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $236 | $236 | $236 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $142 | $310 | $479 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $901 | $901 | $901 |
| Stress echocardiography CPT 93350 • Cardiology | $264 | $264 | $264 |
| Left and right heart catheterization CPT 93452 • Cardiology | $3,391 | $3,391 | $3,391 |
| Left heart catheterization CPT 93458 • Cardiology | $251 | $1,534 | $2,818 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $285 | $764 | $1,243 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $142 | $322 | $502 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $41 | $51 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $178 | $422 | $666 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $138 | $380 | $622 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $54 | $54 | $54 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $274 | $274 | $274 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $70 | $204 | $338 |