| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $2 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $6 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $16 | $16 |
| 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 | $8 | $8 | $8 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $12 | $12 | $12 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $42 | $46 | $49 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $42 | $226 | $410 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $42 | $317 | $592 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $42 | $271 | $501 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $42 | $46 | $49 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $49 | $49 | $49 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $42 | $42 | $42 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,439 | $2,439 | $2,439 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $49 | $49 | $49 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $526 | $526 | $526 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $25 | $25 | $25 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $28 | $28 | $28 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $109 | $109 | $109 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $160 | $160 | $160 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $198 | $198 | $198 |
| Left and right heart catheterization CPT 93452 • Cardiology | $569 | $569 | $569 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $126 | $126 | $126 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $65 | $65 | $65 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $92 | $92 | $92 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $109 | $109 | $109 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $219 | $219 | $219 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $83 | $83 | $83 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $60 | $60 | $60 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $49 | $49 | $49 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $7 | $7 | $7 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $52 | $59 | $65 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $40 | $40 | $40 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $85 | $85 | $85 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $133 | $133 | $133 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $42 | $42 | $42 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $515 | $515 | $515 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,736 | $5,736 | $5,736 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $342 | $342 | $342 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,698 | $1,981 | $2,265 |