| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $15 | $15 | $15 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $6 | $6 | $6 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $14 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $48 | $48 | $48 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $42 | $45 | $48 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $45 | $45 | $45 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $42 | $44 | $45 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,603 | $2,603 | $2,603 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,530 | $2,530 | $2,530 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $600 | $600 | $600 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $508 | $508 | $508 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $306 | $306 | $306 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $201 | $201 | $201 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $252 | $252 | $252 |
| Left and right heart catheterization CPT 93452 • Cardiology | $254 | $254 | $254 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,155 | $1,155 | $1,155 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $11 | $32 | $52 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $18 | $18 | $18 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $74 | $74 | $74 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $38 | $38 | $38 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $89 | $89 | $89 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $146 | $146 | $146 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $209 | $209 | $209 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $105 | $105 | $105 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $46 | $46 | $46 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $97 | $97 | $97 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $108 | $108 | $108 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $4 | $4 | $4 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $67 | $72 | $76 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $39 | $39 | $39 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $485 | $485 | $485 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $126 | $126 | $126 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $7 | $7 | $7 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $879 | $879 | $879 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,500 | $5,500 | $5,500 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $26 | $26 | $26 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,867 | $2,867 | $2,867 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $284 | $284 | $284 |