| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $6 | $6 | $6 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $977 | $4,270 | $9,180 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $977 | $5,632 | $14,941 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $445 | $800 | $977 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $445 | $844 | $977 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $445 | $800 | $977 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $977 | $2,110 | $4,331 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $977 | $3,114 | $8,350 |
| Left and right heart catheterization CPT 93452 • Cardiology | $977 | $1,418 | $1,977 |
| Left heart catheterization CPT 93458 • Cardiology | $977 | $1,418 | $1,977 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $977 | $1,418 | $1,977 |
| Unlisted dental procedure CPT 41899 • Dental | $35 | $35 | $35 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $35 | $551 | $977 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $35 | $408 | $595 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $35 | $328 | $595 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $35 | $333 | $595 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $133 | $419 | $595 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $35 | $742 | $977 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $35 | $663 | $977 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $35 | $663 | $977 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $35 | $522 | $977 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $109 | $412 | $595 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $35 | $408 | $595 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $351 | $641 | $977 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $120 | $606 | $977 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $157 | $425 | $595 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $175 | $429 | $595 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $35 | $478 | $977 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $163 | $617 | $977 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $35 | $408 | $595 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $35 | $408 | $595 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $35 | $408 | $595 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $35 | $340 | $595 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $35 | $408 | $595 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $35 | $455 | $595 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $595 | $595 | $595 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $977 | $1,122 | $1,665 |
| Septoplasty CPT 30520 • ENT | $977 | $1,159 | $1,665 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $559 | $583 | $595 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $35 | $528 | $977 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $559 | $865 | $977 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $977 | $990 | $1,016 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $977 | $1,070 | $1,255 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $977 | $1,174 | $1,922 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $977 | $1,467 | $2,896 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $977 | $1,526 | $2,896 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $35 | $470 | $977 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $977 | $1,613 | $3,483 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $977 | $990 | $1,016 |