| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $2 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $2 | $5 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $13 | $13 | $13 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $35 | $43 | $50 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $35 | $43 | $50 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $35 | $35 | $35 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $35 | $43 | $50 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,371 | $2,371 | $2,371 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,370 | $2,370 | $2,370 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $35 | $35 | $35 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $248 | $248 | $248 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $131 | $131 | $131 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $217 | $217 | $217 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $25 | $25 | $25 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $60 | $60 | $60 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $80 | $80 | $80 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $85 | $85 | $85 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $84 | $84 | $84 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $91 | $91 | $91 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $212 | $212 | $212 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $85 | $85 | $85 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $131 | $131 | $131 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $115 | $115 | $115 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $14 | $42 | $70 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $60 | $60 | $60 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $430 | $430 | $430 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $198 | $198 | $198 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $83 | $83 | $83 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $726 | $726 | $726 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,508 | $8,508 | $8,508 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $305 | $305 | $305 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,561 | $2,960 | $3,359 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $327 | $327 | $327 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $148 | $148 | $148 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $326 | $326 | $326 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $239 | $239 | $239 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $199 | $199 | $199 |