| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $146 | $146 | $146 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $134 | $134 | $134 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $184 | $184 | $184 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $222 | $222 | $222 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $226 | $226 | $226 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $100 | $100 | $100 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $62 | $62 | $62 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $25 | $44 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $156 | $156 | $157 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $106 | $106 | $106 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $124 | $124 | $124 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $118 | $124 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $49 | $61 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $481 | $481 | $481 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $53 | $64 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $92 | $367 | $642 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,353 | $5,353 | $5,353 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $192 | $197 | $202 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $304 | $1,209 | $2,114 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $48 | $423 | $799 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $177 | $177 | $177 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $337 | $337 | $337 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $219 | $219 | $219 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $289 | $289 | $289 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $348 | $348 | $348 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $194 | $194 | $194 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $285 | $285 | $285 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $44 | $225 | $406 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $215 | $215 | $215 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $314 | $314 | $314 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $328 | $328 | $328 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $231 | $231 | $231 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $28 | $28 | $28 |
| Tympanostomy tube insertion CPT 69436 • ENT | $143 | $143 | $143 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $812 | $812 | $812 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $956 | $956 | $956 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $37 | $37 | $37 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $10 | $10 | $10 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $178 | $186 | $194 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $44 | $65 | $86 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $247 | $247 | $247 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $265 | $265 | $265 |
| Initial treatment first degree burn CPT 16000 • Emergency | $69 | $69 | $69 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $69 | $69 | $69 |
| Emergency department visit low severity CPT 99282 • Emergency | $49 | $64 | $78 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $121 | $121 | $121 |