| Allergen specific IgE each allergen CPT 86003 • Allergy | $7 | $7 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $11 | $11 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $241 | $241 | $241 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $422 | $422 | $422 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $543 | $543 | $543 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $422 | $422 | $422 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $543 | $543 | $543 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $483 | $483 | $483 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $362 | $362 | $362 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $483 | $483 | $483 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $362 | $362 | $362 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,264 | $1,264 | $1,264 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $2,230 | $2,230 | $2,230 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $4,528 | $4,528 | $4,528 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $5,316 | $5,316 | $5,316 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,920 | $5,920 | $5,920 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,308 | $1,308 | $1,308 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $1,455 | $1,455 | $1,455 |
| Cardiovascular stress test CPT 93015 • Cardiology | $175 | $175 | $175 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $85 | $85 | $85 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $184 | $184 | $184 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $156 | $156 | $156 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $491 | $491 | $491 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $596 | $596 | $596 |
| Stress echocardiography CPT 93350 • Cardiology | $467 | $467 | $467 |
| Left and right heart catheterization CPT 93452 • Cardiology | $586 | $586 | $586 |
| Left heart catheterization CPT 93458 • Cardiology | $728 | $728 | $728 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $2,845 | $2,845 | $2,845 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $725 | $725 | $725 |
| Septoplasty CPT 30520 • ENT | $1,658 | $1,658 | $1,658 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $536 | $536 | $536 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $458 | $458 | $458 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $623 | $623 | $623 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $1,075 | $1,075 | $1,075 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $790 | $790 | $790 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $437 | $437 | $437 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $646 | $646 | $646 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $921 | $921 | $921 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $328 | $328 | $328 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $709 | $709 | $709 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $740 | $740 | $740 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $621 | $621 | $621 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $515 | $515 | $515 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $81 | $81 | $81 |
| Tympanostomy tube insertion CPT 69436 • ENT | $387 | $387 | $387 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $2,185 | $2,185 | $2,185 |