| Permanent pacemaker insertion CPT 33208 • Cardiology | $4,504 | $8,993 | $16,540 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,744 | $19,327 | $48,336 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $100 | $1,194 | $1,745 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $100 | $1,194 | $1,745 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $100 | $1,057 | $1,744 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $3,926 | $5,082 | $7,036 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $2,037 | $6,493 | $13,564 |
| Left and right heart catheterization CPT 93452 • Cardiology | $1,744 | $2,990 | $4,504 |
| Left heart catheterization CPT 93458 • Cardiology | $3,043 | $4,017 | $4,504 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $2,448 | $3,801 | $4,504 |
| Unlisted dental procedure CPT 41899 • Dental | $128 | $128 | $128 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $128 | $1,340 | $1,745 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $55 | $918 | $1,744 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $128 | $781 | $1,744 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $128 | $947 | $1,744 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $423 | $1,414 | $1,745 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $71 | $1,087 | $1,745 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $71 | $1,086 | $1,745 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $128 | $1,340 | $1,745 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $128 | $1,340 | $1,745 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $176 | $1,080 | $1,745 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $128 | $1,027 | $1,745 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $221 | $1,033 | $1,744 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $194 | $1,217 | $1,823 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $255 | $1,182 | $1,745 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $423 | $1,160 | $1,744 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $128 | $982 | $1,745 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $193 | $1,065 | $1,823 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $128 | $1,232 | $1,745 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $128 | $1,340 | $1,745 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $128 | $1,340 | $1,745 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $128 | $1,015 | $1,745 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $71 | $1,086 | $1,745 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $121 | $1,096 | $1,745 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $1,744 | $1,744 | $1,744 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $1,450 | $1,925 | $2,704 |
| Septoplasty CPT 30520 • ENT | $1,450 | $2,158 | $2,704 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $639 | $1,243 | $1,744 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $128 | $1,160 | $1,823 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $639 | $1,529 | $1,823 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $1,450 | $2,686 | $4,704 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $1,992 | $3,398 | $4,704 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $1,450 | $2,716 | $3,123 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $1,450 | $2,725 | $4,704 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $1,744 | $2,816 | $4,704 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $128 | $1,120 | $1,745 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $1,450 | $2,614 | $3,003 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $1,450 | $2,743 | $3,432 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $1,450 | $2,245 | $2,704 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $1,450 | $2,279 | $2,704 |