| 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 | $110 | $190 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $132 | $234 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $21 | $21 | $21 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $61 | $91 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $69 | $108 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $126 | $126 | $127 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $122 | $131 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $175 | $175 | $175 |
| 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 | $13 | $34 | $54 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $46 | $46 | $46 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $69 | $69 | $69 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $7 | $42 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $695 | $811 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $6,380 | $6,380 | $6,380 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $270 | $270 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,041 | $3,041 | $3,041 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $210 | $210 | $210 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $269 | $269 | $269 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $799 | $799 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $145 | $145 | $146 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $179 | $328 |
| Septoplasty CPT 30520 • ENT | $752 | $752 | $752 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $119 | $207 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $156 | $282 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $487 | $487 | $487 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $194 | $357 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $197 | $197 | $197 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $21 | $26 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $21 | $21 | $21 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $168 | $305 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $268 | $268 | $268 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $126 | $222 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $97 | $163 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,093 | $1,093 | $1,094 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $42 | $42 | $42 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $75 | $119 |
| 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 | $143 | $199 | $255 |