| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $4 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $7 | $7 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $18 | $18 | $18 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $5 | $5 | $5 |
| 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 | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $40 | $40 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,029 | $2,029 | $2,029 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $494 | $494 | $494 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $549 | $549 | $549 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $64 | $64 | $64 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $56 | $56 | $56 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $193 | $193 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $253 | $253 | $253 |
| Left and right heart catheterization CPT 93452 • Cardiology | $239 | $239 | $239 |
| Left heart catheterization CPT 93458 • Cardiology | $294 | $294 | $294 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $124 | $124 | $124 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $153 | $153 | $153 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $36 | $38 | $40 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $43 | $43 | $43 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $83 | $83 | $83 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $52 | $52 | $52 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $29 | $29 | $29 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $64 | $64 | $64 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $187 | $187 | $187 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $40 | $40 | $40 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $99 | $99 | $99 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $23 | $23 | $23 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $5 | $6 | $7 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $7 | $23 | $38 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $51 | $51 | $51 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $476 | $476 | $476 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $143 | $143 | $143 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $63 | $63 | $63 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $649 | $649 | $649 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $7,767 | $7,767 | $7,767 |