| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $165 | $165 | $165 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $94 | $94 | $94 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $112 | $112 | $112 |
| 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 | $319 | $319 |
| Septoplasty CPT 30520 • ENT | $632 | $632 | $632 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $133 | $133 | $133 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $329 | $329 | $329 |
| 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 | $82 | $82 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $237 | $237 | $237 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $171 | $171 | $171 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $300 | $300 | $300 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $286 | $286 | $286 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $131 | $131 | $131 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $102 | $102 | $102 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $42 | $42 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $206 | $206 | $206 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $31 | $31 | $31 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $94 | $94 | $94 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $155 | $155 | $155 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $37 | $37 | $37 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $49 | $49 | $49 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $48 | $48 | $48 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $223 | $223 | $223 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $121 | $121 | $121 |
| Emergency department visit low severity CPT 99282 • Emergency | $41 | $41 | $41 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $65 | $65 | $65 |
| Emergency department visit high severity CPT 99284 • Emergency | $113 | $113 | $113 |
| Emergency department visit highest severity CPT 99285 • Emergency | $205 | $205 | $205 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $196 | $196 | $196 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $98 | $98 | $98 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $144 | $144 | $144 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $115 | $115 | $115 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $118 | $118 | $118 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $113 | $113 | $113 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $380 | $380 | $380 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $164 | $164 | $164 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $207 | $207 | $207 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $525 | $525 | $525 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $150 | $150 | $150 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $214 | $214 | $214 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $167 | $167 | $167 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $116 | $116 | $116 |