| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $7 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $17 | $17 | $17 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $2 | $2 | $2 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • 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 abdominal wall surgery CPT 00840 • 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 cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $979 | $979 | $979 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,336 | $2,336 | $2,336 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,601 | $2,601 | $2,601 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $34 | $34 | $34 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $118 | $118 | $118 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $222 | $222 | $222 |
| Left and right heart catheterization CPT 93452 • Cardiology | $219 | $219 | $219 |
| Left heart catheterization CPT 93458 • Cardiology | $717 | $717 | $717 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $756 | $756 | $756 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $147 | $147 | $147 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $62 | $62 | $62 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $71 | $71 | $71 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $6 | $6 | $6 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $101 | $101 | $101 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $90 | $90 | $90 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $42 | $42 | $42 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $48 | $48 | $48 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $114 | $114 | $114 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $12 | $30 | $48 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $40 | $40 | $40 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $377 | $377 | $377 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $130 | $130 | $130 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $55 | $55 | $55 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $680 | $680 | $680 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,868 | $5,868 | $5,868 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $197 | $197 | $197 |