| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $9 | $9 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $708 | $708 | $708 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,543 | $2,543 | $2,543 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,986 | $2,986 | $2,986 |
| Cardiovascular stress test CPT 93015 • Cardiology | $71 | $71 | $71 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $35 | $35 | $35 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $261 | $261 | $261 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $240 | $240 | $240 |
| Stress echocardiography CPT 93350 • Cardiology | $187 | $187 | $187 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,118 | $1,118 | $1,118 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $239 | $239 | $239 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $76 | $76 | $76 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $167 | $167 | $167 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $109 | $109 | $109 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $131 | $131 | $131 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $114 | $114 | $114 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $125 | $125 | $125 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $138 | $138 | $138 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $168 | $168 | $168 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $154 | $154 | $154 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $213 | $213 | $213 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $264 | $264 | $264 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $75 | $75 | $75 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $72 | $72 | $72 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $7 | $7 | $7 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $182 | $182 | $182 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $122 | $122 | $122 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $142 | $142 | $142 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $116 | $116 | $116 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $60 | $60 | $60 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $60 | $60 | $60 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $732 | $732 | $732 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $223 | $223 | $223 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,402 | $2,402 | $2,402 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $452 | $452 | $452 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $188 | $188 | $188 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $356 | $356 | $356 |