| Allergen immunotherapy injection single CPT 95115 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,872 | $1,872 | $1,872 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,975 | $3,975 | $3,975 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $4,371 | $4,371 | $4,371 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $5,197 | $5,197 | $5,197 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $52 | $52 | $52 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $17 | $17 | $17 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $30 | $30 | $30 |
| Cardiovascular stress test CPT 93015 • Cardiology | $246 | $246 | $246 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $126 | $126 | $126 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $266 | $266 | $266 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $186 | $186 | $186 |
| Stress echocardiography CPT 93350 • Cardiology | $366 | $366 | $366 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $128 | $128 | $128 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $128 | $128 | $128 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $139 | $139 | $139 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $76 | $76 | $76 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $114 | $114 | $114 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $91 | $91 | $91 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $99 | $99 | $99 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $61 | $61 | $61 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $76 | $76 | $76 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $91 | $91 | $91 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $91 | $91 | $91 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $114 | $114 | $114 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $144 | $144 | $144 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $175 | $175 | $175 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $228 | $228 | $228 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $76 | $76 | $76 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $68 | $68 | $68 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $10 | $10 | $10 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $46 | $46 | $46 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $16 | $16 | $16 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $532 | $532 | $532 |
| Septoplasty CPT 30520 • ENT | $1,027 | $1,027 | $1,027 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $75 | $75 | $75 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $878 | $878 | $878 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $1,429 | $1,429 | $1,429 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $607 | $607 | $607 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $1,046 | $1,046 | $1,046 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $107 | $107 | $107 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $419 | $419 | $419 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $452 | $452 | $452 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $435 | $435 | $435 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $238 | $238 | $238 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $20 | $20 | $20 |
| Tympanostomy tube insertion CPT 69436 • ENT | $338 | $338 | $338 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,847 | $1,847 | $1,847 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $2,004 | $2,004 | $2,004 |