| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $175 | $237 | $360 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $190 | $428 | $903 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $186 | $251 | $360 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $152 | $391 | $903 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $66 | $345 | $903 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $296 | $498 | $903 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $352 | $536 | $903 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $117 | $310 | $382 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $308 | $506 | $903 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $162 | $228 | $360 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $61 | $157 | $360 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $96 | $360 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $231 | $274 | $360 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $102 | $200 | $360 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $202 | $255 | $360 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $5,281 | $5,281 | $5,281 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $274 | $274 | $274 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $812 | $812 | $812 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $674 | $1,756 | $3,920 |
| Septoplasty CPT 30520 • ENT | $960 | $1,947 | $3,920 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $155 | $644 | $1,725 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $319 | $333 | $360 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $397 | $840 | $1,725 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $429 | $1,593 | $3,920 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $628 | $2,116 | $5,092 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $310 | $1,513 | $3,920 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $498 | $1,639 | $3,920 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $793 | $2,226 | $5,092 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $295 | $316 | $360 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $455 | $1,610 | $3,920 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $474 | $1,623 | $3,920 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $396 | $1,570 | $3,920 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $325 | $1,524 | $3,920 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $43 | $139 | $360 |
| Tympanostomy tube insertion CPT 69436 • ENT | $223 | $612 | $1,725 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,374 | $2,925 | $6,029 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,624 | $3,093 | $6,029 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $44 | $44 | $44 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $121 | $211 | $360 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $320 | $345 | $382 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $50 | $171 | $360 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $167 | $232 | $360 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $168 | $232 | $360 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $251 | $335 | $365 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $261 | $354 | $397 |
| Initial treatment first degree burn CPT 16000 • Emergency | $107 | $191 | $360 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $31 | $31 | $31 |
| Emergency department visit low severity CPT 99282 • Emergency | $48 | $57 | $61 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $81 | $88 | $91 |
| Emergency department visit high severity CPT 99284 • Emergency | $139 | $162 | $173 |