| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $46 | $61 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $48 | $66 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $73 | $73 | $73 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $82 | $133 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $107 | $184 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $129 | $227 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $49 | $61 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $18 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $62 | $94 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $76 | $104 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $112 | $121 | $129 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $123 | $134 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $185 | $185 | $185 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $73 | $73 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $63 | $63 | $63 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $582 | $582 | $582 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $13 | $107 | $200 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $76 | $76 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $60 | $561 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $9,080 | $9,080 | $9,080 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $270 | $270 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,041 | $3,041 | $3,041 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $379 | $379 | $379 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $800 | $800 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $333 | $338 | $343 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $254 | $478 |
| Septoplasty CPT 30520 • ENT | $1,096 | $1,096 | $1,096 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $350 | $350 | $350 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $154 | $299 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $257 | $411 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $709 | $709 | $709 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $281 | $531 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $175 | $175 | $175 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $46 | $61 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $304 | $577 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $504 | $504 | $504 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $224 | $417 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $42 | $42 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $154 | $226 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,037 | $1,273 | $1,509 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $38 | $45 |