| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $58 | $100 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $67 | $104 |
| 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 | $47 | $64 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $71 | $118 |
| 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 | $68 | $106 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $38 | $45 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $222 | $222 | $222 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $45 | $45 | $45 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $45 | $45 | $45 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $57 | $84 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $43 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $18 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $52 | $81 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $45 | $67 | $112 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $112 | $112 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $59 | $66 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $43 | $43 | $43 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $13 | $96 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $76 | $76 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $60 | $360 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,071 | $8,071 | $8,071 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $270 | $270 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $304 | $1,137 | $1,970 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $1,015 | $1,015 | $1,015 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $800 | $800 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $175 | $175 | $175 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $38 | $45 |
| Septoplasty CPT 30520 • ENT | $45 | $45 | $45 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $69 | $133 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $135 | $329 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $45 | $45 | $45 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $38 | $45 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $45 | $45 | $45 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $145 | $259 |
| 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 | $30 | $38 | $45 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $45 | $45 | $45 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $38 | $45 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $35 | $35 | $35 |
| Tympanostomy tube insertion CPT 69436 • ENT | $45 | $99 | $206 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $45 | $45 | $45 |