| Allergen specific IgE each allergen CPT 86003 • Allergy | $4 | $4 | $4 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $16 | $16 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $9 | $9 |
| 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 | $42 | $42 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $42 | $42 | $42 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $42 | $42 | $42 |
| 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 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $951 | $951 | $951 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,275 | $2,275 | $2,275 |
| 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 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $37 | $37 | $37 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $279 | $279 | $279 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $208 | $208 | $208 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $252 | $252 | $252 |
| Left and right heart catheterization CPT 93452 • Cardiology | $710 | $710 | $710 |
| Left heart catheterization CPT 93458 • Cardiology | $797 | $797 | $797 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $197 | $197 | $197 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $160 | $160 | $160 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $52 | $52 | $52 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $27 | $27 | $27 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $74 | $74 | $74 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $77 | $77 | $77 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $108 | $108 | $108 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $179 | $179 | $179 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $49 | $49 | $49 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $97 | $97 | $97 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $4 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $76 | $76 | $76 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $55 | $55 | $55 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $688 | $688 | $688 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $182 | $182 | $182 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $7 | $7 | $7 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $700 | $700 | $700 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $7,863 | $7,863 | $7,863 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $208 | $208 | $208 |