| CPT | Service Category | Copay | Rate $ | Description | Covered? | Auth Req. |
| 0003A | IMMUNIZATIONS/VACCINATIONS | $0 Copay | 41.24 | (SARS-COV2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, MRNA-LNP, SPIKE PROTEIN, PRESERVATIVE FREE, 30 MCG/0.3 ML DOSAGE, DILUENT RECONSTITUTED; THIRD DOSE | COVERED | N |
| 0004A | IMMUNIZATIONS/VACCINATIONS | $0 Copay | 41.24 | (SARSCOV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, MRNALNP, SPIKE PROTEIN, PRESERVATIVE FREE, 30 MCG/0.3 ML DOSAGE, DILUENT RECONSTITUTED; BOOSTER DOSE | COVERED | N |
| 0013A | IMMUNIZATIONS/VACCINATIONS | $0 Copay | 40.00 | (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) VACCINE, MRNA-LNP, SPIKE PROTEIN, PRESERVATIVE FREE, 100 MCG/0.5 ML DOSAGE; THIRD DOSE | COVERED | N |
| 0107U | LAB TEST - OTHER | Cap - $0 / Off - $50 | 16.00 | C DIFF TOX AG DETCJ IA STOOL | COVERED | Y |
| 0108U | LAB TEST - OTHER | Cap - $0 / Off - $50 | 2350.00 | GI BARRETT ESOPH 9 PRTN BMRK | COVERED | Y |
| 0112U | LAB TEST - OTHER | Cap - $0 / Off - $50 | 356.13 | IADI 16S&18S RRNA GENES | COVERED | Y |
| 0119U | LAB TEST - OTHER | Cap - $0 / Off - $50 | 83.76 | CRD CERAMIDES LIQ CHROM PLSM | COVERED | Y |
| 0191T | EYE PROCEDURE - OTHER | $350 copay (Per Day) | 354.84 | INSERT ANT SEGMENT DRAIN INT | COVERED | Y |
| 01960 | ANESTHESIA | $100 copay (Per Day) | 2000.00 | ANESTH VAGINAL DELIVERY | COVERED | N |
| 01961 | ANESTHESIA | $100 copay (Per Day) | 356.76 | ANESTH CS DELIVERY | COVERED | N |
| 0439T | ECHOGRAPHY - HEART | Cap - $0 / Other- $250 / OP - $250 (Per Day) | 75.90 | MYOCRD CONTRAST PRFUJ ECHO | COVERED | Y |
| 10004 | MINOR PROCEDURES - OTHER | Cap - $0 / Off - $25 /UR - $75 / ASC - $400 (Per Day) /OP - $500 (Per day) | 53.36 | FNA BX W/O IMG GDN EA ADDL | COVERED | Y |
| 10005 | MINOR PROCEDURES - OTHER | Off - $25 /UR - $75 / ASC - $400 (Per Day) /OP - $500 (Per day) | 145.75 | FNA BX W/US GDN 1ST LES | COVERED | Y |
| 10021 | MINOR PROCEDURES - OTHER | Cap - $0 / Off - $25 /UR - $75 / ASC - $400 (Per Day) /OP - $500 (Per day) | 107.11 | FNA W/O IMAGE | COVERED | Y |
| 10040 | MINOR PROCEDURES - SKIN | Cap - $0 / Off - $25 /UR - $75 / ASC - $400 (Per Day) /OP - $500 (Per day) | 122.55 | ACNE SURGERY | COVERED | Y |
| 10060 | MINOR PROCEDURES - SKIN | Cap - $0 / Off - $25 /UR - $75 / ASC - $400 (Per Day) /OP - $500 (Per day) | 130.99 | DRAINAGE OF SKIN ABSCESS | COVERED | Y |