| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $141 | $141 | $141 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $30 | $30 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $120 | $120 | $120 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $173 | $173 | $173 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $67 | $69 | $70 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $35 | $35 | $35 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $457 | $457 | $457 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $121 | $121 | $121 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $76 | $76 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $927 | $927 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,165 | $5,165 | $5,165 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $202 | $202 | $202 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $304 | $1,432 | $2,561 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $212 | $212 | $212 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $327 | $327 | $327 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $148 | $165 | $182 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $30 | $30 |
| Septoplasty CPT 30520 • 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 | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $30 | $30 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $30 | $30 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $981 | $981 | $981 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $30 | $30 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $40 | $40 | $40 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $30 | $30 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $44 | $44 | $44 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $30 | $81 | $131 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $30 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $30 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $10 | $15 | $21 |
| Emergency department visit low severity CPT 99282 • Emergency | $40 | $49 | $58 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $61 | $65 | $69 |
| Emergency department visit high severity CPT 99284 • Emergency | $115 | $130 | $156 |
| Emergency department visit highest severity CPT 99285 • Emergency | $168 | $169 | $171 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $30 | $30 | $30 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $30 | $30 | $30 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $174 | $174 | $174 |