| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $6 | $7 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $11 | $26 | $34 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $794 | $28,717 | $71,609 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,396 | $29,840 | $73,526 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,850 | $4,575 | $7,189 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,353 | $4,883 | $7,189 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,744 | $5,121 | $7,189 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $857 | $16,537 | $40,620 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $954 | $16,596 | $40,620 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $27 | $27 | $27 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $13 | $13 | $13 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $14 | $14 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $120 | $122 | $123 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $60 | $61 | $62 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $142 | $144 | $146 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $272 | $340 | $378 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $356 | $362 | $364 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $387 | $393 | $397 |
| Stress echocardiography CPT 93350 • Cardiology | $375 | $382 | $385 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,281 | $12,740 | $30,334 |
| Left heart catheterization CPT 93458 • Cardiology | $492 | $12,691 | $30,334 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,735 | $13,017 | $30,334 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $256 | $297 | $322 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $137 | $139 | $141 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $402 | $408 | $411 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $306 | $311 | $313 |
| Unlisted dental procedure CPT 41899 • Dental | $517 | $517 | $517 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $26 | $238 | $517 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $36 | $246 | $517 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $502 | $510 | $517 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $147 | $328 | $517 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $6,072 | $6,162 | $6,252 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $56 | $274 | $517 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $179 | $313 | $517 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $148 | $294 | $517 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $169 | $307 | $517 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $184 | $2,577 | $6,252 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $161 | $326 | $517 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $177 | $2,600 | $6,252 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $200 | $2,587 | $6,252 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $286 | $2,640 | $6,252 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $233 | $2,649 | $6,252 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $370 | $430 | $517 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $298 | $2,647 | $6,252 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $88 | $285 | $517 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $82 | $260 | $517 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $8 | $209 | $517 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $223 | $340 | $517 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $164 | $304 | $517 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $195 | $323 | $517 |