| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $36 | $42 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $30 | $36 | $42 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $36 | $42 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $97 | $164 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $42 | $42 | $42 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $121 | $212 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $36 | $42 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $97 | $163 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $62 | $94 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $71 | $112 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $64 | $88 | $112 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $136 | $136 | $136 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $47 | $60 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $62 | $62 | $62 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $69 | $69 | $69 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $184 | $184 | $184 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $76 | $76 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $754 | $841 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $9,052 | $9,052 | $9,052 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $228 | $249 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,376 | $2,709 | $3,041 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $198 | $198 | $198 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $800 | $800 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $160 | $247 | $333 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $248 | $466 |
| Septoplasty CPT 30520 • ENT | $657 | $657 | $657 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $30 | $30 | $30 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $126 | $222 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $152 | $273 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $288 | $288 | $288 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $227 | $423 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $36 | $42 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $36 | $42 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $184 | $337 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $292 | $292 | $292 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $136 | $241 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $46 | $46 | $46 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $90 | $149 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $503 | $975 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $32 | $32 |