| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $131 | $131 | $131 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $120 | $120 | $120 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $170 | $170 | $170 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $218 | $218 | $218 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $89 | $89 | $89 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $48 | $67 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $132 | $147 | $163 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $97 | $97 | $97 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $115 | $115 | $115 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $72 | $72 | $73 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $156 | $156 | $156 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $4 | $4 | $4 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $4 | $5 | $6 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $28 | $31 | $34 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $48 | $48 | $48 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $518 | $518 | $518 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $75 | $75 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $92 | $424 | $755 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $6,856 | $6,856 | $6,856 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $202 | $223 | $243 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $304 | $1,357 | $2,411 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $178 | $178 | $178 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $357 | $578 | $799 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $144 | $144 | $145 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $441 | $441 | $441 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $210 | $210 | $210 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $256 | $256 | $257 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $267 | $267 | $267 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $391 | $391 | $391 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $194 | $194 | $194 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $33 | $172 | $311 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $494 | $494 | $494 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $25 | $25 | $25 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $294 | $294 | $294 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $306 | $306 | $306 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $212 | $212 | $212 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $29 | $29 | $29 |
| Tympanostomy tube insertion CPT 69436 • ENT | $161 | $161 | $161 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $891 | $891 | $891 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,050 | $1,050 | $1,050 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $37 | $37 | $37 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $102 | $102 | $102 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $181 | $194 | $207 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $44 | $62 | $80 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $97 | $97 | $97 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $209 | $209 | $209 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $228 | $228 | $228 |
| Initial treatment first degree burn CPT 16000 • Emergency | $61 | $61 | $61 |