| 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 | $5 | $7 | $12 |
| Allergy testing insect venoms CPT 95017 • Allergy | $26 | $26 | $26 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $59 | $59 | $59 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $14 | $23 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $21 | $29 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $14 | $25 | $34 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $24 | $44 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $109 | $447 | $732 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $59 | $511 | $732 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $109 | $481 | $732 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $109 | $335 | $488 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $109 | $432 | $854 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $59 | $858 | $1,416 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $59 | $474 | $854 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $109 | $493 | $732 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $59 | $605 | $1,098 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $59 | $530 | $976 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $109 | $476 | $732 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $109 | $509 | $976 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $59 | $563 | $732 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $756 | $1,121 | $1,485 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $33 | $1,298 | $2,618 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $413 | $2,870 | $5,327 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,872 | $5,063 | $6,254 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $6,957 | $6,957 | $6,957 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,768 | $1,768 | $1,768 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $560 | $1,116 | $1,971 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $23 | $34 | $43 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $16 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $16 | $25 |
| Cardiovascular stress test CPT 93015 • Cardiology | $120 | $181 | $242 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $43 | $82 | $120 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $247 | $247 | $247 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $890 | $890 | $890 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $311 | $531 | $750 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $232 | $314 | $432 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $124 | $319 | $442 |
| Stress echocardiography CPT 93350 • Cardiology | $154 | $346 | $634 |
| Left and right heart catheterization CPT 93452 • Cardiology | $793 | $793 | $793 |
| Left heart catheterization CPT 93458 • Cardiology | $403 | $1,344 | $2,539 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $2,130 | $3,795 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $41 | $292 | $569 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $37 | $74 | $110 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $242 | $429 | $714 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $254 | $361 | $560 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $199 | $199 | $199 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $230 | $230 | $230 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $81 | $166 | $283 |