| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $7 | $9 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $5 | $5 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $27 | $27 | $27 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $10 | $10 | $11 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $11 | $12 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $13 | $14 | $14 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $17 | $21 | $25 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $55 | $275 | $496 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $55 | $288 | $521 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $55 | $298 | $542 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $55 | $253 | $451 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $55 | $194 | $333 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $55 | $736 | $1,416 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $55 | $177 | $300 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $55 | $236 | $416 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $55 | $377 | $700 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $55 | $294 | $533 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $55 | $334 | $612 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $55 | $293 | $531 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $55 | $393 | $730 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,241 | $1,241 | $1,241 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,243 | $1,712 | $2,181 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,580 | $3,525 | $4,470 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $620 | $2,941 | $5,262 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,875 | $5,875 | $5,875 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $754 | $754 | $754 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $817 | $828 | $840 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $23 | $26 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $14 | $14 | $14 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $13 | $15 |
| Cardiovascular stress test CPT 93015 • Cardiology | $96 | $99 | $102 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $44 | $47 | $51 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $120 | $120 | $120 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $104 | $104 | $104 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $222 | $267 | $311 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $88 | $95 | $102 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $151 | $155 | $158 |
| Stress echocardiography CPT 93350 • Cardiology | $99 | $207 | $316 |
| Left and right heart catheterization CPT 93452 • Cardiology | $749 | $749 | $749 |
| Left heart catheterization CPT 93458 • Cardiology | $524 | $926 | $1,328 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $465 | $471 | $477 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $265 | $268 | $271 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $23 | $68 | $113 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $71 | $201 | $330 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $62 | $158 | $254 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $33 | $33 | $33 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $113 | $113 | $113 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $132 | $179 | $214 |