| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $45 | $45 | $45 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $101 | $101 | $101 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $25 | $45 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $45 | $63 | $81 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $45 | $67 | $112 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $84 | $84 | $84 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $44 | $51 | $59 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $34 | $34 | $34 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $43 | $43 | $43 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $13 | $69 | $124 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $41 | $41 | $41 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $60 | $282 | $505 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $4,958 | $4,958 | $4,958 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $131 | $131 | $131 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $196 | $1,083 | $1,970 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $419 | $419 | $419 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $175 | $175 | $175 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $45 | $45 | $45 |
| Septoplasty CPT 30520 • ENT | $45 | $45 | $45 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $115 | $115 | $115 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $45 | $105 | $165 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $45 | $187 | $329 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $45 | $45 | $45 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $45 | $45 | $45 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $45 | $45 | $45 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $45 | $45 | $45 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $45 | $45 | $45 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $45 | $45 | $45 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $45 | $45 | $45 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $36 | $36 | $36 |
| Tympanostomy tube insertion CPT 69436 • ENT | $45 | $99 | $206 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $45 | $45 | $45 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $29 | $30 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $45 | $83 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $155 | $155 | $155 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $45 | $45 | $45 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $45 | $91 | $183 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $45 | $70 | $121 |
| Initial treatment first degree burn CPT 16000 • Emergency | $45 | $45 | $45 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $25 | $25 | $25 |
| Emergency department visit low severity CPT 99282 • Emergency | $34 | $34 | $34 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $51 | $58 | $65 |
| Emergency department visit high severity CPT 99284 • Emergency | $113 | $120 | $125 |
| Emergency department visit highest severity CPT 99285 • Emergency | $126 | $155 | $184 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $45 | $121 | $198 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $45 | $45 | $45 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $45 | $108 | $235 |