| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $1 | $5 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $2 | $3 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $8 | $12 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $10 | $13 | $15 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $1 | $3 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $11 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $2 | $10 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $6 | $11 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $48 | $59 | $80 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $48 | $65 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $23 | $44 | $80 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $53 | $80 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $48 | $65 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $23 | $50 | $80 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $48 | $65 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $23 | $50 | $80 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $23 | $50 | $80 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $23 | $50 | $80 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $23 | $50 | $80 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $53 | $80 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $53 | $80 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $695 | $702 | $710 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $746 | $1,069 | $1,237 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $206 | $1,749 | $2,543 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $483 | $1,708 | $2,933 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $1,342 | $2,302 | $3,262 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $101 | $449 | $740 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $588 | $667 | $824 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $8 | $14 | $19 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $6 | $12 | $21 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $13 | $22 |
| Cardiovascular stress test CPT 93015 • Cardiology | $37 | $70 | $100 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $8 | $31 | $49 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $73 | $125 | $199 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $260 | $296 | $366 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $45 | $143 | $297 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $99 | $167 | $202 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $132 | $143 | $154 |
| Stress echocardiography CPT 93350 • Cardiology | $38 | $109 | $190 |
| Left and right heart catheterization CPT 93452 • Cardiology | $248 | $419 | $677 |
| Left heart catheterization CPT 93458 • Cardiology | $787 | $960 | $1,049 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $468 | $658 | $848 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $53 | $114 | $151 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $12 | $37 | $81 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $44 | $177 | $267 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $47 | $149 | $250 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $9 | $21 | $31 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $35 | $78 | $110 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $8 | $30 | $51 |