| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $77 | $77 | $77 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $98 | $98 | $98 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $118 | $118 | $118 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $45 | $45 | $45 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $167 | $167 | $167 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $223 | $223 | $223 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $32 | $32 | $32 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $45 | $45 | $45 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $51 | $51 | $51 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $45 | $45 | $45 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $101 | $101 | $101 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $120 | $120 | $120 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $73 | $73 | $73 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $180 | $180 | $180 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $27 | $27 | $27 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $8 | $8 | $8 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $34 | $40 | $46 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $60 | $60 | $60 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $43 | $43 | $43 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $160 | $160 | $160 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $31 | $31 | $31 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $505 | $505 | $505 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,690 | $8,690 | $8,690 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $232 | $232 | $232 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,969 | $2,512 | $3,056 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $313 | $313 | $313 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $808 | $808 | $808 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $504 | $504 | $504 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $208 | $208 | $208 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $398 | $398 | $398 |
| Septoplasty CPT 30520 • ENT | $559 | $559 | $559 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $32 | $32 | $32 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $175 | $175 | $175 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $297 | $297 | $297 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $249 | $249 | $249 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $365 | $365 | $365 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $181 | $181 | $181 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $289 | $289 | $289 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $32 | $32 | $32 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $145 | $174 | $203 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $310 | $310 | $310 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $263 | $263 | $263 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $269 | $269 | $269 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $222 | $222 | $222 |
| Tympanostomy tube insertion CPT 69436 • ENT | $186 | $186 | $187 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $759 | $759 | $759 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,196 | $1,196 | $1,196 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $41 | $41 | $41 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $100 | $100 | $100 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $144 | $144 | $144 |