| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $59 | $172 | $228 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $62 | $62 | $62 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $246 | $246 | $246 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $42 | $91 | $153 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $68 | $68 | $68 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $165 | $165 | $165 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $112 | $138 | $151 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $130 | $161 | $176 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $93 | $93 | $93 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $94 | $94 | $94 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $22 | $22 | $22 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $33 | $33 | $33 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $121 | $121 | $121 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $36 | $36 | $36 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $319 | $368 | $392 |
| Septoplasty CPT 30520 • ENT | $632 | $810 | $900 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $184 | $226 | $247 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $273 | $273 | $273 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $331 | $331 | $331 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $166 | $166 | $166 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $82 | $165 | $239 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $237 | $314 | $352 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $171 | $391 | $501 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $256 | $256 | $256 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $300 | $361 | $392 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $286 | $368 | $409 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $131 | $273 | $344 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $102 | $225 | $286 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $49 | $59 | $64 |
| Tympanostomy tube insertion CPT 69436 • ENT | $154 | $194 | $214 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $877 | $1,031 | $1,185 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $31 | $31 | $31 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $86 | $141 | $169 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $149 | $240 | $286 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $37 | $95 | $124 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $49 | $117 | $151 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $48 | $115 | $148 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $153 | $283 | $348 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $278 | $313 | $375 |
| Initial treatment first degree burn CPT 16000 • Emergency | $106 | $106 | $106 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $21 | $39 | $57 |
| Emergency department visit low severity CPT 99282 • Emergency | $41 | $58 | $76 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $98 | $129 |
| Emergency department visit high severity CPT 99284 • Emergency | $113 | $165 | $219 |
| Emergency department visit highest severity CPT 99285 • Emergency | $205 | $253 | $318 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $196 | $352 | $496 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $98 | $159 | $218 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $207 | $207 | $207 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $145 | $301 | $379 |