| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $136 | $136 | $136 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $79 | $107 | $153 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $46 | $46 | $46 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $7 | $7 | $7 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $111 | $111 | $111 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $101 | $134 | $151 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $104 | $152 | $176 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $17 | $17 | $17 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $75 | $75 | $75 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $96 | $96 | $96 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $22 | $22 | $22 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $11 | $11 | $11 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $121 | $121 | $121 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $1,030 | $1,030 | $1,030 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $150 | $150 | $150 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $410 | $410 | $410 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $800 | $800 | $800 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $392 | $392 | $392 |
| Septoplasty CPT 30520 • ENT | $900 | $900 | $900 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $247 | $247 | $247 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $175 | $207 | $239 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $352 | $352 | $352 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $501 | $501 | $501 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $256 | $256 | $256 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $336 | $373 | $392 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $350 | $389 | $409 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $344 | $344 | $344 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $286 | $286 | $286 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $41 | $56 | $64 |
| Tympanostomy tube insertion CPT 69436 • ENT | $186 | $204 | $214 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $877 | $1,003 | $1,185 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $35 | $35 | $35 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $82 | $140 | $169 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $146 | $239 | $286 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $50 | $100 | $124 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $68 | $123 | $151 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $31 | $109 | $148 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $78 | $258 | $348 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $125 | $259 | $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 | $52 | $62 | $76 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $78 | $101 | $129 |
| Emergency department visit high severity CPT 99284 • Emergency | $156 | $179 | $219 |
| Emergency department visit highest severity CPT 99285 • Emergency | $222 | $258 | $318 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $264 | $375 | $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 | $142 | $300 | $379 |