| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $1 | $1 | $1 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $7 | $11 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $10 | $18 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $21 | $33 | $45 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $11 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $21 | $21 | $21 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $25 | $25 | $25 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $6 | $10 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $35 | $45 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $35 | $45 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $38 | $45 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $35 | $45 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,013 | $1,013 | $1,013 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,750 | $1,750 | $1,750 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,588 | $3,588 | $3,588 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,376 | $3,264 | $4,153 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $4,603 | $4,603 | $4,603 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,094 | $1,094 | $1,094 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,215 | $1,215 | $1,215 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $41 | $41 | $41 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $24 | $24 | $24 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $17 | $17 | $17 |
| Cardiovascular stress test CPT 93015 • Cardiology | $196 | $196 | $196 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $119 | $119 | $119 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $235 | $235 | $235 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $79 | $119 | $160 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $67 | $99 | $130 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $136 | $195 | $253 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $220 | $293 | $367 |
| Stress echocardiography CPT 93350 • Cardiology | $152 | $152 | $152 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,104 | $1,436 | $1,767 |
| Left heart catheterization CPT 93458 • Cardiology | $1,555 | $1,555 | $1,555 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,320 | $1,874 | $2,428 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $59 | $115 | $171 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $239 | $239 | $239 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $611 | $611 | $611 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $195 | $349 | $502 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $30 | $52 | $85 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $59 | $59 | $59 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $198 | $198 | $198 |