| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $7 | $7 | $7 |
| Allergy testing insect venoms CPT 95017 • Allergy | $15 | $15 | $15 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $34 | $34 | $34 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $2 | $2 | $2 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $17 | $17 | $17 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $19 | $19 | $19 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $25 | $25 | $25 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $750 | $8,819 | $16,026 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $750 | $25,351 | $43,926 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $57 | $403 | $750 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $57 | $403 | $750 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $57 | $403 | $750 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $750 | $750 | $750 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $750 | $4,778 | $8,805 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $24 | $24 | $24 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $10 | $10 | $10 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $14 | $14 | $14 |
| Cardiovascular stress test CPT 93015 • Cardiology | $120 | $120 | $120 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $59 | $59 | $59 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $122 | $122 | $122 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $440 | $440 | $440 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $371 | $371 | $371 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $331 | $331 | $331 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $402 | $402 | $402 |
| Stress echocardiography CPT 93350 • Cardiology | $314 | $314 | $314 |
| Left and right heart catheterization CPT 93452 • Cardiology | $750 | $750 | $750 |
| Left heart catheterization CPT 93458 • Cardiology | $750 | $1,417 | $2,084 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $750 | $1,417 | $2,084 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $321 | $321 | $321 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $137 | $137 | $137 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $403 | $403 | $403 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $316 | $316 | $316 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $57 | $403 | $750 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $57 | $403 | $750 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $57 | $299 | $750 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $57 | $403 | $750 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $57 | $316 | $750 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $57 | $403 | $750 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $57 | $403 | $750 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $57 | $403 | $750 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $57 | $403 | $750 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $750 | $7,113 | $13,476 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $132 | $4,786 | $13,476 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $144 | $4,790 | $13,476 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $126 | $4,752 | $13,476 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $166 | $4,797 | $13,476 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $184 | $4,803 | $13,476 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $197 | $4,808 | $13,476 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $171 | $4,767 | $13,476 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $57 | $403 | $750 |