| Permanent pacemaker insertion CPT 33208 • Cardiology | $1,645 | $4,424 | $15,042 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $328 | $2,890 | $7,069 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $285 | $317 | $328 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $285 | $317 | $328 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $285 | $314 | $328 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $1,390 | $3,358 | $7,097 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $328 | $5,023 | $13,682 |
| Left and right heart catheterization CPT 93452 • Cardiology | $328 | $1,737 | $3,239 |
| Left heart catheterization CPT 93458 • Cardiology | $1,200 | $1,607 | $1,811 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,200 | $1,997 | $3,239 |
| Unlisted dental procedure CPT 41899 • Dental | $106 | $106 | $106 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $106 | $284 | $350 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $53 | $215 | $350 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $106 | $218 | $350 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $106 | $245 | $350 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $218 | $324 | $350 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $68 | $232 | $328 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $68 | $232 | $328 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $106 | $273 | $328 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $106 | $250 | $328 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $178 | $311 | $350 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $106 | $268 | $350 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $328 | $343 | $350 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $196 | $652 | $904 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $258 | $332 | $350 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $287 | $334 | $350 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $106 | $281 | $350 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $186 | $407 | $904 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $106 | $284 | $350 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $106 | $284 | $350 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $106 | $284 | $350 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $106 | $253 | $350 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $68 | $245 | $350 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $106 | $255 | $350 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $350 | $350 | $350 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $850 | $891 | $904 |
| Septoplasty CPT 30520 • ENT | $850 | $1,485 | $2,728 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $350 | $677 | $1,286 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $106 | $604 | $904 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $721 | $997 | $1,550 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $850 | $2,050 | $4,745 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $1,050 | $1,963 | $4,745 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $850 | $1,357 | $3,150 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $850 | $1,791 | $4,745 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $328 | $1,724 | $4,745 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $106 | $280 | $350 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $850 | $1,869 | $5,707 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $328 | $1,421 | $2,728 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $850 | $1,467 | $2,728 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $850 | $1,403 | $2,728 |