| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $33 | $34 | $34 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $794 | $23,720 | $69,550 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,396 | $24,747 | $71,412 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,850 | $4,253 | $6,982 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $3,353 | $4,593 | $6,982 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,744 | $4,857 | $6,982 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $857 | $13,729 | $39,452 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $954 | $13,794 | $39,452 |
| 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 | $369 | $373 | $378 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $356 | $360 | $364 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $387 | $392 | $397 |
| Stress echocardiography CPT 93350 • Cardiology | $375 | $380 | $385 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,281 | $10,685 | $29,462 |
| Left heart catheterization CPT 93458 • Cardiology | $1,565 | $10,877 | $29,462 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,735 | $10,992 | $29,462 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $314 | $318 | $322 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $137 | $139 | $141 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $402 | $406 | $411 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $306 | $310 | $313 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $71 | $215 | $502 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $87 | $226 | $502 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $502 | $502 | $502 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $147 | $324 | $502 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $6,072 | $6,072 | $6,072 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $145 | $265 | $502 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $179 | $288 | $502 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $148 | $267 | $502 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $169 | $282 | $502 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $184 | $2,148 | $6,072 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $222 | $317 | $502 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $247 | $2,191 | $6,072 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $200 | $2,159 | $6,072 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $286 | $2,217 | $6,072 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $341 | $2,254 | $6,072 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $370 | $417 | $502 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $298 | $2,225 | $6,072 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $157 | $273 | $502 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $99 | $234 | $502 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $8 | $173 | $502 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $223 | $318 | $502 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $164 | $278 | $502 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $195 | $299 | $502 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $952 | $952 | $952 |