| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $132 | $234 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $195 | $195 | $195 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $156 | $156 | $156 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $106 | $106 | $106 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $77 | $124 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $111 | $111 | $111 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $156 | $156 | $156 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $46 | $46 | $46 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $38 | $38 | $38 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $49 | $49 | $49 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $127 | $127 | $127 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $54 | $54 | $54 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $660 | $660 | $660 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,750 | $5,750 | $5,750 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $19 | $19 | $19 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,624 | $1,895 | $2,167 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $266 | $266 | $266 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $578 | $578 | $578 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $240 | $240 | $241 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $193 | $355 |
| Septoplasty CPT 30520 • ENT | $808 | $808 | $808 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $265 | $265 | $265 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $231 | $231 | $231 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $307 | $307 | $307 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $525 | $525 | $525 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $396 | $396 | $396 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $324 | $324 | $324 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $338 | $338 | $338 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $293 | $293 | $293 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $242 | $242 | $242 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $36 | $36 | $36 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $100 | $169 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $587 | $1,144 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $38 | $38 | $38 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $117 | $117 | $117 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $43 | $43 | $43 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $30 | $30 | $30 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $108 | $108 | $108 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $150 | $269 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $37 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $58 | $58 | $58 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $71 | $71 |