| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $81 | $131 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $36 | $41 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $40 | $49 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $30 | $60 | $90 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $121 | $212 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $264 | $264 | $264 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $136 | $136 | $136 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $33 | $35 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $16 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $76 | $121 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $142 | $142 | $142 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $116 | $116 | $116 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $157 | $157 | $157 |
| 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 | $44 | $52 | $60 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $41 | $41 | $41 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $69 | $69 | $69 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $141 | $141 | $141 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $60 | $68 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $732 | $732 | $732 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $6,373 | $6,373 | $6,373 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $202 | $212 | $223 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $240 | $1,321 | $2,402 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $208 | $208 | $208 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $544 | $544 | $544 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $452 | $452 | $452 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $188 | $188 | $188 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $193 | $355 |
| Septoplasty CPT 30520 • ENT | $814 | $814 | $814 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $182 | $182 | $182 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $127 | $224 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $169 | $307 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $525 | $525 | $525 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $210 | $390 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $217 | $217 | $217 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $243 | $455 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $188 | $346 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $304 | $304 | $304 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $141 | $252 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $51 | $51 | $51 |
| Tympanostomy tube insertion CPT 69436 • ENT | $175 | $175 | $175 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |