| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $20 | $20 | $20 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $11 | $11 | $11 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $10 | $10 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $44 | $47 | $50 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $44 | $47 | $50 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $50 | $50 | $50 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $44 | $44 | $44 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $44 | $44 | $44 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $904 | $904 | $904 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $1,815 | $1,815 | $1,815 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,578 | $2,578 | $2,578 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,868 | $2,868 | $2,868 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $139 | $139 | $139 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $148 | $148 | $148 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $206 | $206 | $206 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $44 | $44 | $44 |
| Left and right heart catheterization CPT 93452 • Cardiology | $145 | $145 | $145 |
| Left heart catheterization CPT 93458 • Cardiology | $1,111 | $1,111 | $1,111 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $121 | $121 | $121 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $2 | $29 | $56 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $65 | $65 | $65 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $44 | $44 | $44 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $33 | $33 | $33 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $63 | $63 | $63 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $80 | $80 | $80 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $87 | $87 | $87 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $112 | $112 | $112 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $108 | $108 | $108 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $158 | $158 | $158 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $99 | $99 | $99 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $49 | $49 | $49 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $44 | $44 | $44 |
| 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 | $49 | $53 | $58 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $38 | $38 | $38 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $48 | $48 | $48 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $124 | $124 | $124 |