| Allergen specific IgE each allergen CPT 86003 • Allergy | $9 | $9 | $9 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $13 | $13 | $13 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $17 | $17 | $17 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $10 | $10 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,706 | $1,706 | $1,706 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $3,376 | $3,376 | $3,376 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $4,770 | $4,770 | $4,770 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $5,293 | $5,293 | $5,293 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,748 | $5,748 | $5,748 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $46 | $46 | $46 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $33 | $33 | $33 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $25 | $25 | $25 |
| Cardiovascular stress test CPT 93015 • Cardiology | $235 | $235 | $235 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $186 | $186 | $186 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $289 | $289 | $289 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $260 | $260 | $260 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $221 | $221 | $221 |
| Stress echocardiography CPT 93350 • Cardiology | $85 | $85 | $85 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $97 | $180 | $264 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $114 | $154 | $194 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $296 | $300 | $304 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $257 | $296 | $335 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $41 | $41 | $41 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $53 | $53 | $53 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $64 | $64 | $64 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $78 | $78 | $78 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $70 | $70 | $70 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $79 | $79 | $79 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $111 | $111 | $111 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $123 | $123 | $123 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $188 | $188 | $188 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $169 | $169 | $169 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $163 | $163 | $163 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $250 | $250 | $250 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $329 | $329 | $329 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $239 | $239 | $239 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $83 | $83 | $83 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $67 | $67 | $67 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $16 | $16 | $16 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $237 | $237 | $237 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $69 | $69 | $69 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $88 | $88 | $88 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $193 | $193 | $193 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $616 | $616 | $616 |
| Septoplasty CPT 30520 • ENT | $1,428 | $1,428 | $1,428 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $130 | $130 | $130 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $445 | $445 | $445 |