| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $5 | $5 | $5 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $8 | $18 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $450 | $1,912 | $6,297 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $450 | $2,682 | $9,377 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $309 | $415 | $450 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $309 | $415 | $450 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $309 | $415 | $450 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $450 | $796 | $1,832 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $450 | $796 | $1,832 |
| Left and right heart catheterization CPT 93452 • Cardiology | $450 | $734 | $1,584 |
| Left heart catheterization CPT 93458 • Cardiology | $450 | $734 | $1,584 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $450 | $734 | $1,584 |
| Unlisted dental procedure CPT 41899 • Dental | $99 | $275 | $450 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $99 | $362 | $450 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $99 | $362 | $450 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $99 | $362 | $450 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $99 | $362 | $450 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $226 | $394 | $450 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $99 | $362 | $450 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $99 | $362 | $450 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $99 | $362 | $450 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $99 | $362 | $450 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $226 | $394 | $450 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $99 | $362 | $450 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $226 | $394 | $450 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $226 | $525 | $625 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $226 | $394 | $450 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $226 | $394 | $450 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $99 | $362 | $450 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $226 | $525 | $625 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $99 | $362 | $450 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $99 | $362 | $450 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $99 | $362 | $450 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $99 | $362 | $450 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $99 | $362 | $450 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $99 | $362 | $450 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $450 | $450 | $450 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $450 | $670 | $978 |
| Septoplasty CPT 30520 • ENT | $450 | $582 | $978 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $420 | $443 | $450 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $99 | $450 | $625 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $420 | $574 | $625 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $450 | $582 | $978 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $450 | $635 | $1,189 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $450 | $582 | $978 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $450 | $582 | $978 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $450 | $635 | $1,189 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $99 | $362 | $450 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $450 | $582 | $978 |