| Allergen specific IgE each allergen CPT 86003 • Allergy | $5 | $5 | $5 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $8 | $8 | $8 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $8 | $8 | $8 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $10 | $10 | $10 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $3 | $3 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $30 | $30 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $30 | $30 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $30 | $30 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $177 | $177 | $177 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $193 | $193 | $193 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $235 | $235 | $235 |
| Left and right heart catheterization CPT 93452 • Cardiology | $905 | $905 | $905 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,120 | $1,120 | $1,120 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $38 | $38 | $38 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $149 | $149 | $149 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $70 | $70 | $70 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $100 | $100 | $100 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $139 | $139 | $139 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $122 | $122 | $122 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $65 | $65 | $65 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $109 | $109 | $109 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $129 | $129 | $129 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $13 | $43 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $69 | $69 | $69 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $76 | $76 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $927 | $927 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,071 | $8,071 | $8,071 |