| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $143 | $143 | $143 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $147 | $264 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $33 | $36 |
| 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 | $62 | $94 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $70 | $109 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $86 | $142 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $114 | $116 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $13 | $36 | $60 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $690 | $690 | $690 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $60 | $68 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $92 | $412 | $732 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,071 | $8,071 | $8,071 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $223 | $246 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $304 | $1,353 | $2,402 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $452 | $626 | $799 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $188 | $188 | $188 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $30 | $30 |
| Septoplasty CPT 30520 • ENT | $30 | $30 | $30 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $30 | $30 | $30 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $30 | $30 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $217 | $217 | $217 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $200 | $369 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $109 | $188 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $118 | $206 |
| Tympanostomy tube insertion CPT 69436 • ENT | $155 | $165 | $175 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $454 | $877 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $594 | $1,159 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $30 | $30 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $119 | $207 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $109 | $109 | $109 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $257 | $270 | $283 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $168 | $306 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $30 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $8 | $54 | $76 |
| Emergency department visit low severity CPT 99282 • Emergency | $41 | $56 | $76 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $69 | $84 | $104 |