| Allergen specific IgE each allergen CPT 86003 • Allergy | $3 | $3 | $3 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $3 |
| Allergy testing insect venoms CPT 95017 • Allergy | $6 | $6 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $16 | $16 | $16 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $8 | $8 | $8 |
| 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 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,439 | $2,439 | $2,439 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,715 | $2,715 | $2,715 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $473 | $473 | $473 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $109 | $109 | $109 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $160 | $160 | $160 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $193 | $193 | $193 |
| Stress echocardiography CPT 93350 • Cardiology | $42 | $42 | $42 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $35 | $35 | $35 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $65 | $65 | $65 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $19 | $19 | $19 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $92 | $92 | $92 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $39 | $39 | $39 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $73 | $73 | $73 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $93 | $93 | $93 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $129 | $129 | $129 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $219 | $219 | $219 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $43 | $43 | $43 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $48 | $48 | $48 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $85 | $85 | $85 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $42 | $42 | $42 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $7 | $7 | $7 |
| 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 | $52 | $52 | $52 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $40 | $40 | $40 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $515 | $515 | $515 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $133 | $133 | $133 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $5 | $5 | $5 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $515 | $515 | $515 |