| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $280 | $280 | $280 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $490 | $490 | $490 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $630 | $630 | $630 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $490 | $490 | $490 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $630 | $630 | $630 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $560 | $560 | $560 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $420 | $420 | $420 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $560 | $560 | $560 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $420 | $420 | $420 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $323 | $1,766 | $6,945 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $323 | $5,683 | $21,370 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $323 | $445 | $520 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $323 | $445 | $520 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $323 | $426 | $520 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $520 | $1,032 | $2,056 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $520 | $1,032 | $2,056 |
| Left and right heart catheterization CPT 93452 • Cardiology | $520 | $946 | $1,798 |
| Left heart catheterization CPT 93458 • Cardiology | $520 | $946 | $1,798 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $520 | $840 | $1,798 |
| Unlisted dental procedure CPT 41899 • Dental | $109 | $109 | $109 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $50 | $332 | $520 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $50 | $270 | $460 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $109 | $368 | $520 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $109 | $368 | $520 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $249 | $426 | $520 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $50 | $344 | $520 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $50 | $344 | $520 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $50 | $344 | $520 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $50 | $344 | $520 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $249 | $426 | $520 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $109 | $398 | $520 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $249 | $403 | $520 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $249 | $429 | $525 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $249 | $414 | $520 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $249 | $403 | $520 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $109 | $398 | $520 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $249 | $404 | $525 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $50 | $332 | $520 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $50 | $344 | $520 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $50 | $344 | $520 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $109 | $398 | $520 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $50 | $344 | $520 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $50 | $344 | $520 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $520 | $520 | $520 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $498 | $630 | $1,079 |
| Septoplasty CPT 30520 • ENT | $495 | $715 | $1,079 |