| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $41 | $41 | $41 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $93 | $93 | $93 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $41 | $41 | $41 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $93 | $93 | $93 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $41 | $41 | $41 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $41 | $41 | $41 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $41 | $41 | $41 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $41 | $41 | $41 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $41 | $85 | $129 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $41 | $41 | $41 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $73 | $73 | $73 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $177 | $177 | $177 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $33 | $33 | $33 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $44 | $44 | $44 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $251 | $251 | $251 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $791 | $791 | $791 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $411 | $411 | $411 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $203 | $203 | $203 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $41 | $41 | $41 |
| Septoplasty CPT 30520 • ENT | $41 | $41 | $41 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $41 | $41 | $41 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $41 | $41 | $41 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $41 | $41 | $41 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $41 | $41 | $41 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $41 | $41 | $41 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $41 | $41 | $41 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $41 | $41 | $41 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $41 | $41 | $41 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $41 | $41 | $41 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $41 | $41 | $41 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $41 | $41 | $41 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $41 | $41 | $41 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $41 | $41 | $41 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $41 | $49 | $57 |
| Tympanostomy tube insertion CPT 69436 • ENT | $41 | $41 | $41 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $41 | $41 | $41 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $990 | $990 | $990 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $35 | $35 | $35 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $41 | $95 | $149 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $41 | $148 | $255 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $41 | $86 | $131 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $41 | $100 | $160 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $41 | $41 | $41 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $41 | $41 | $41 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $41 | $41 | $41 |
| Initial treatment first degree burn CPT 16000 • Emergency | $41 | $41 | $41 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $18 | $18 | $18 |