| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $8 | $8 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $6 | $8 | $10 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $10 | $22 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $30 | $52 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $12 | $20 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $17 | $25 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $2 | $14 | $30 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $22 | $39 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $32 | $53 | $93 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $32 | $53 | $93 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $32 | $55 | $101 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $32 | $53 | $93 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $32 | $55 | $101 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $33 | $571 | $1,331 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $458 | $1,402 | $2,345 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $33 | $2,402 | $4,772 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $717 | $2,584 | $5,603 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $799 | $3,516 | $6,232 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $253 | $797 | $1,341 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $84 | $789 | $1,495 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $16 | $23 | $37 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $2 | $9 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $8 | $12 | $21 |
| Cardiovascular stress test CPT 93015 • Cardiology | $76 | $112 | $183 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $8 | $50 | $91 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $47 | $109 | $187 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $40 | $265 | $675 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $161 | $172 | $183 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $232 | $316 | $508 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $154 | $247 | $308 |
| Stress echocardiography CPT 93350 • Cardiology | $123 | $223 | $301 |
| Left and right heart catheterization CPT 93452 • Cardiology | $663 | $1,294 | $2,317 |
| Left heart catheterization CPT 93458 • Cardiology | $289 | $1,102 | $1,926 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $326 | $1,186 | $2,029 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $37 | $246 | $492 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $32 | $57 | $92 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $37 | $296 | $617 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $32 | $200 | $397 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $8 | $75 | $185 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $3 | $87 | $213 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $3 | $44 | $99 |