| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $5 | $5 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $803 | $803 | $803 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,522 | $1,522 | $1,522 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,624 | $2,624 | $2,624 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,951 | $2,951 | $2,951 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,277 | $3,277 | $3,277 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $45 | $45 | $45 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $16 | $16 | $16 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $12 | $12 | $12 |
| Cardiovascular stress test CPT 93015 • Cardiology | $116 | $116 | $116 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $59 | $59 | $59 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $170 | $170 | $170 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $246 | $246 | $246 |
| Stress echocardiography CPT 93350 • Cardiology | $254 | $254 | $254 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $180 | $180 | $180 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $68 | $68 | $68 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $180 | $180 | $180 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $188 | $188 | $188 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $43 | $43 | $43 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $62 | $62 | $62 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $49 | $49 | $49 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $58 | $58 | $58 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $57 | $57 | $57 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $79 | $79 | $79 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $100 | $100 | $100 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $73 | $73 | $73 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $101 | $101 | $101 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $133 | $133 | $133 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $157 | $157 | $157 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $127 | $127 | $127 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $64 | $64 | $64 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $43 | $43 | $43 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $39 | $39 | $39 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $21 | $21 | $21 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $279 | $279 | $279 |
| Septoplasty CPT 30520 • ENT | $595 | $595 | $595 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $66 | $66 | $66 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $75 | $75 | $75 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $189 | $189 | $189 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $469 | $469 | $469 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $735 | $735 | $735 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $311 | $311 | $311 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $415 | $415 | $415 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $618 | $618 | $618 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $108 | $108 | $108 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $297 | $297 | $297 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $355 | $355 | $355 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $311 | $311 | $311 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $194 | $194 | $194 |