| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $192 | $192 | $192 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $30 | $30 | $30 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $86 | $86 | $86 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $51 | $51 | $51 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $0 | $0 | $0 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $96 | $96 | $96 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $8 | $58 | $109 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $103 | $103 | $103 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $106 | $106 | $106 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $61 | $67 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $12 | $33 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $96 | $393 | $690 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $31 | $104 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $15 | $50 | $68 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $92 | $364 | $826 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,071 | $8,071 | $8,071 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $37 | $152 | $241 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $270 | $1,489 | $2,708 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $411 | $605 | $799 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $171 | $171 | $171 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $271 | $271 | $271 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $179 | $179 | $179 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $234 | $234 | $234 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $296 | $296 | $296 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $165 | $165 | $165 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $243 | $243 | $243 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $346 | $346 | $346 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $174 | $174 | $174 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $260 | $260 | $260 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $271 | $271 | $271 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $187 | $187 | $187 |
| Tympanostomy tube insertion CPT 69436 • ENT | $138 | $138 | $138 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $795 | $795 | $795 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $937 | $937 | $937 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $96 | $108 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $164 | $164 | $165 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $51 | $72 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $109 | $109 | $109 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $205 | $205 | $205 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $220 | $220 | $220 |
| Initial treatment first degree burn CPT 16000 • Emergency | $57 | $57 | $58 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $56 | $56 | $56 |
| Emergency department visit low severity CPT 99282 • Emergency | $56 | $56 | $56 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $68 | $86 | $104 |
| Emergency department visit high severity CPT 99284 • Emergency | $156 | $156 | $156 |
| Emergency department visit highest severity CPT 99285 • Emergency | $174 | $185 | $195 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $211 | $241 | $271 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $30 | $61 | $93 |