| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $2 | $2 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $88 | $145 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $120 | $120 | $120 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $173 | $173 | $173 |
| 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 | $50 | $59 | $67 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $35 | $35 | $35 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $343 | $343 | $343 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $121 | $121 | $121 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $4 | $4 | $4 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $54 | $54 | $54 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,165 | $5,165 | $5,165 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $181 | $181 | $181 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,051 | $2,051 | $2,052 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $212 | $212 | $212 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $394 | $394 | $394 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $182 | $182 | $183 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $170 | $310 |
| Septoplasty CPT 30520 • ENT | $30 | $30 | $30 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $30 | $30 | $30 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $30 | $30 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $203 | $203 | $203 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $299 | $299 | $299 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $212 | $212 | $212 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $30 | $30 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $30 | $30 | $30 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $30 | $30 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $596 | $1,163 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $40 | $40 | $40 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $94 | $157 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $280 | $280 | $280 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $67 | $83 | $99 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $65 | $65 | $65 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $273 | $273 | $273 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $30 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $30 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $21 | $21 | $21 |
| Emergency department visit low severity CPT 99282 • Emergency | $40 | $52 | $64 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $61 | $85 | $110 |
| Emergency department visit high severity CPT 99284 • Emergency | $116 | $150 | $185 |