| 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 | $55 | $81 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $112 | $113 | $115 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $112 | $112 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $70 | $70 | $70 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $13 | $13 | $13 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $77 | $77 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $60 | $493 | $927 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $270 | $270 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,561 | $2,561 | $2,561 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $800 | $800 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $148 | $148 | $148 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $30 | $30 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $81 | $133 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $180 | $329 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $199 | $199 | $199 |
| 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 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $35 | $35 | $35 |
| Tympanostomy tube insertion CPT 69436 • ENT | $149 | $177 | $206 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $968 | $968 | $968 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $32 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $76 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $92 | $155 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $183 | $204 | $225 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $121 | $182 | $243 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $30 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $22 | $22 | $22 |
| Emergency department visit low severity CPT 99282 • Emergency | $42 | $42 | $42 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $71 | $71 |
| Emergency department visit high severity CPT 99284 • Emergency | $113 | $135 | $156 |
| Emergency department visit highest severity CPT 99285 • Emergency | $174 | $174 | $174 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $30 | $114 | $198 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $91 | $91 | $91 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $151 | $151 | $151 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $144 | $203 | $262 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $30 | $72 | $115 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $348 | $348 | $348 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $118 | $118 | $118 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $113 | $113 | $113 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $212 | $212 | $212 |