| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $6 | $6 | $6 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $5 | $5 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $12 | $12 | $12 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $15 | $15 | $15 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $3 | $3 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $642 | $2,754 | $8,490 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $642 | $3,882 | $13,000 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $365 | $500 | $642 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $365 | $473 | $642 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $365 | $500 | $642 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $365 | $1,769 | $4,000 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $365 | $1,655 | $4,000 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $29 | $29 | $29 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $19 | $19 | $19 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $115 | $115 | $115 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $70 | $70 | $70 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $175 | $175 | $175 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $184 | $184 | $184 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $239 | $239 | $239 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $298 | $298 | $298 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $290 | $290 | $290 |
| Stress echocardiography CPT 93350 • Cardiology | $163 | $163 | $163 |
| Left and right heart catheterization CPT 93452 • Cardiology | $365 | $1,603 | $3,500 |
| Left heart catheterization CPT 93458 • Cardiology | $365 | $1,603 | $3,500 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $943 | $1,795 | $3,500 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $225 | $225 | $225 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $123 | $123 | $123 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $274 | $274 | $274 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $41 | $41 | $41 |
| Unlisted dental procedure CPT 41899 • Dental | $180 | $180 | $180 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $50 | $265 | $365 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $50 | $229 | $365 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $180 | $377 | $642 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $180 | $388 | $642 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $365 | $483 | $642 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $50 | $265 | $365 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $50 | $240 | $365 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $50 | $240 | $365 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $50 | $240 | $365 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $85 | $357 | $559 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $32 | $249 | $419 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $365 | $427 | $559 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $147 | $381 | $559 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $365 | $427 | $559 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $32 | $344 | $559 |