| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $8 | $8 | $8 |
| Allergy testing insect venoms CPT 95017 • Allergy | $4 | $4 | $5 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $27 | $27 | $27 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $13 | $13 | $13 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $16 | $16 | $16 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $4 | $4 | $4 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $50 | $50 | $50 |
| 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 | $50 | $50 | $50 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $50 | $50 | $50 |
| 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 | $50 | $50 | $50 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,860 | $2,860 | $2,860 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $760 | $760 | $760 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $96 | $96 | $96 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $296 | $296 | $296 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $411 | $411 | $411 |
| Left and right heart catheterization CPT 93452 • Cardiology | $324 | $324 | $324 |
| Left heart catheterization CPT 93458 • Cardiology | $944 | $944 | $944 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $196 | $196 | $196 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $51 | $51 | $51 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $72 | $72 | $72 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $50 | $50 | $50 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $258 | $258 | $258 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $50 | $50 | $50 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $115 | $115 | $115 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $138 | $138 | $138 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $20 | $20 | $20 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $6 | $6 | $7 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $38 | $38 | $38 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $50 | $50 | $50 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $698 | $698 | $698 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $158 | $158 | $158 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $69 | $69 | $69 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $953 | $953 | $953 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,535 | $8,535 | $8,535 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $30 | $30 | $30 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,001 | $3,001 | $3,001 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $530 | $530 | $530 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $219 | $219 | $219 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $481 | $481 | $481 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $148 | $148 | $148 |