| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $88 | $88 | $88 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $148 | $148 | $148 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $103 | $147 | $190 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $96 | $96 | $96 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $57 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $118 | $118 | $118 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $81 | $84 | $87 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $94 | $98 | $102 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $75 | $75 | $75 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $157 | $157 | $157 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $6 | $6 | $6 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $9 | $9 | $9 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $63 | $68 | $73 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $739 | $739 | $739 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $14 | $91 | $167 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $38 | $55 | $73 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $79 | $537 | $995 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $9,031 | $9,031 | $9,031 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $243 | $243 | $243 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,175 | $3,175 | $3,175 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $243 | $243 | $243 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $161 | $223 | $285 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $355 | $355 | $355 |
| Septoplasty CPT 30520 • ENT | $491 | $491 | $491 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $172 | $172 | $172 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $205 | $205 | $205 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $208 | $208 | $208 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $304 | $304 | $304 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $151 | $151 | $151 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $383 | $383 | $383 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $289 | $289 | $289 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $252 | $252 | $252 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $210 | $210 | $210 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $35 | $35 | $35 |
| Tympanostomy tube insertion CPT 69436 • ENT | $139 | $139 | $139 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $907 | $907 | $907 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $27 | $32 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $90 | $100 | $110 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $32 | $32 | $32 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $84 | $84 | $84 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $111 | $111 | $111 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $198 | $198 | $198 |
| Initial treatment first degree burn CPT 16000 • Emergency | $33 | $33 | $33 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $55 | $55 | $55 |
| Emergency department visit low severity CPT 99282 • Emergency | $59 | $59 | $59 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $88 | $88 | $88 |
| Emergency department visit high severity CPT 99284 • Emergency | $159 | $159 | $159 |
| Emergency department visit highest severity CPT 99285 • Emergency | $246 | $246 | $246 |