| Permanent pacemaker insertion CPT 33208 • Cardiology | $749 | $749 | $749 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,229 | $1,229 | $1,229 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,430 | $2,430 | $2,430 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,712 | $2,712 | $2,712 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,960 | $2,960 | $2,960 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $15 | $15 | $15 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $49 | $49 | $49 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $68 | $68 | $68 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $36 | $36 | $36 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $40 | $40 | $40 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $80 | $80 | $80 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $101 | $101 | $101 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $124 | $124 | $124 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $98 | $98 | $98 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $124 | $124 | $124 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $154 | $154 | $154 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $180 | $180 | $180 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $150 | $150 | $150 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $72 | $72 | $72 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $48 | $48 | $48 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $15 | $15 | $15 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $222 | $222 | $222 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $53 | $53 | $53 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $72 | $72 | $72 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $29 | $29 | $29 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $10 | $10 | $10 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $64 | $64 | $64 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $91 | $91 | $91 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $168 | $168 | $168 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $239 | $239 | $239 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $145 | $145 | $145 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $98 | $98 | $98 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $309 | $309 | $309 |
| Septoplasty CPT 30520 • ENT | $540 | $540 | $540 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $84 | $84 | $84 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $78 | $78 | $78 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $277 | $277 | $277 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $424 | $424 | $424 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $635 | $635 | $635 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $298 | $298 | $298 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $471 | $471 | $471 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $686 | $686 | $686 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $129 | $129 | $129 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $311 | $311 | $311 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $376 | $376 | $376 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $321 | $321 | $321 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $211 | $211 | $211 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $46 | $46 | $46 |
| Tympanostomy tube insertion CPT 69436 • ENT | $182 | $182 | $182 |