| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $5 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $17 | $18 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $7 | $8 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $10 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $12 | $17 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $8 | $15 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $58 | $86 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $44 | $79 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $58 | $108 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $98 | $178 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $52 | $109 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $67 | $167 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $75 | $158 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $55 | $119 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $72 | $178 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $61 | $147 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $77 | $198 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $69 | $128 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $99 | $294 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $225 | $420 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $740 | $740 | $740 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $30 | $1,430 | $2,831 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $1,678 | $3,327 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,711 | $4,355 | $4,998 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $428 | $428 | $428 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $476 | $476 | $476 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $10 | $18 | $26 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $14 | $14 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $62 | $81 | $110 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $33 | $59 | $79 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $59 | $98 | $136 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $226 | $257 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $286 | $322 | $359 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $53 | $114 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $91 | $178 | $235 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $72 | $114 |
| Left and right heart catheterization CPT 93452 • Cardiology | $190 | $316 | $441 |
| Left heart catheterization CPT 93458 • Cardiology | $238 | $1,016 | $1,794 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $270 | $837 | $1,120 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $125 | $176 | $268 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $20 | $41 | $62 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $171 | $215 | $240 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $32 | $193 | $329 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $42 | $60 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $58 | $69 | $80 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $69 | $74 | $79 |