| 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 | $371 | $371 | $371 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $371 | $371 | $371 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $371 | $371 | $371 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $139 | $247 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $433 | $433 | $433 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $556 | $556 | $556 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $231 | $433 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $371 | $371 | $371 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $556 | $556 | $556 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $494 | $494 | $494 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $200 | $371 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $494 | $494 | $494 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $371 | $371 | $371 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $507 | $588 | $669 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,177 | $1,177 | $1,177 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $678 | $678 | $678 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $755 | $755 | $755 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $8 | $8 | $8 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $49 | $49 | $49 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $290 | $290 | $290 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $260 | $260 | $260 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $313 | $313 | $313 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,157 | $1,157 | $1,157 |
| Left heart catheterization CPT 93458 • Cardiology | $1,343 | $1,343 | $1,343 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,445 | $1,445 | $1,445 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $249 | $249 | $249 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $108 | $108 | $108 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $315 | $315 | $315 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $245 | $245 | $245 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $165 | $165 | $165 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $170 | $170 | $170 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $207 | $207 | $207 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $228 | $228 | $228 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $79 | $116 | $153 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $151 | $151 | $151 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $176 | $176 | $176 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $392 | $392 | $392 |
| Septoplasty CPT 30520 • ENT | $900 | $900 | $900 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $247 | $247 | $247 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $175 | $207 | $239 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $352 | $352 | $352 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $501 | $501 | $501 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $256 | $256 | $256 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $392 | $392 | $392 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $409 | $409 | $409 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $344 | $344 | $344 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $286 | $286 | $286 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $64 | $64 | $64 |