| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $2 | $2 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $5 | $6 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $14 | $14 | $14 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $10 | $10 | $10 |
| 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 | $2,130 | $2,130 | $2,130 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,370 | $2,370 | $2,370 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $89 | $89 | $89 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $39 | $39 | $39 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $131 | $131 | $131 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $158 | $158 | $158 |
| Left heart catheterization CPT 93458 • Cardiology | $181 | $181 | $181 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $150 | $150 | $150 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $122 | $122 | $122 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $11 | $34 | $57 |
| 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 | $81 | $81 | $81 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $34 | $34 | $34 |
| 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 | $122 | $122 | $122 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $190 | $190 | $190 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $38 | $38 | $38 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $74 | $74 | $74 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $104 | $104 | $104 |
| 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 | $14 | $46 | $78 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $60 | $60 | $60 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $764 | $764 | $764 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $198 | $198 | $198 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $8 | $8 | $8 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $1,019 | $1,019 | $1,019 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,508 | $8,508 | $8,508 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $30 | $30 | $30 |