| 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 | $70 | $109 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $129 | $129 | $129 |
| 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 | $54 | $64 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $690 | $690 | $690 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $76 | $76 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $92 | $510 | $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 | $27 | $149 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,041 | $3,041 | $3,041 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $800 | $800 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $333 | $333 | $333 |
| Submucous resection inferior turbinate CPT 30140 • 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 total CPT 31255 • ENT | $30 | $30 | $30 |
| 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 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • 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 | $1,037 | $1,037 | $1,037 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $76 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $30 | $30 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $61 | $91 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $109 | $109 | $109 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $258 | $258 | $258 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $30 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $37 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $22 | $22 | $22 |
| Emergency department visit low severity CPT 99282 • Emergency | $42 | $60 | $78 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $88 | $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 | $30 | $151 | $271 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $30 | $68 | $106 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $151 | $151 | $151 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $296 | $296 | $296 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $30 | $204 | $378 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $384 | $384 | $384 |