| Permanent pacemaker insertion CPT 33208 • Cardiology | $450 | $3,370 | $8,948 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $450 | $8,968 | $29,002 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $450 | $450 | $450 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $450 | $450 | $450 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $450 | $450 | $450 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $450 | $2,036 | $4,222 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $450 | $3,774 | $8,138 |
| Left and right heart catheterization CPT 93452 • Cardiology | $450 | $1,047 | $1,927 |
| Left heart catheterization CPT 93458 • Cardiology | $450 | $1,047 | $1,927 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $450 | $1,047 | $1,927 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $40 | $423 | $600 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $45 | $415 | $600 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $84 | $351 | $600 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $104 | $363 | $600 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $130 | $378 | $600 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $58 | $352 | $450 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $58 | $319 | $450 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $53 | $318 | $450 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $58 | $263 | $450 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $103 | $352 | $600 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $115 | $359 | $600 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $126 | $327 | $600 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $109 | $456 | $800 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $147 | $375 | $600 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $171 | $386 | $600 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $182 | $434 | $600 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $157 | $391 | $800 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $58 | $419 | $600 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $58 | $369 | $600 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $402 | $600 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $118 | $325 | $600 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $58 | $419 | $600 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $98 | $437 | $600 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $600 | $600 | $600 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $450 | $1,062 | $1,637 |
| Septoplasty CPT 30520 • ENT | $450 | $882 | $1,623 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $491 | $614 | $765 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $122 | $461 | $800 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $800 | $980 | $1,399 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $450 | $1,430 | $2,823 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $450 | $1,430 | $2,823 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $450 | $1,044 | $1,996 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $450 | $1,430 | $2,823 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $450 | $1,430 | $2,823 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $144 | $400 | $600 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $450 | $1,483 | $3,395 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $450 | $1,040 | $1,637 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $450 | $1,040 | $1,637 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $450 | $1,040 | $1,637 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $33 | $411 | $600 |