| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $96 | $96 | $96 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $9 | $9 | $9 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $158 | $158 | $158 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $115 | $115 | $115 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $153 | $153 | $153 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $323 | $323 | $323 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $747 | $747 | $747 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $265 | $265 | $265 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $415 | $415 | $415 |
| Septoplasty CPT 30520 • ENT | $945 | $945 | $945 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $302 | $302 | $302 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $264 | $264 | $264 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $372 | $372 | $372 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $613 | $613 | $613 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $257 | $257 | $257 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $376 | $376 | $376 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $536 | $536 | $536 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $269 | $269 | $269 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $419 | $419 | $419 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $436 | $436 | $436 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $368 | $368 | $368 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $306 | $306 | $306 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $68 | $68 | $68 |
| Tympanostomy tube insertion CPT 69436 • ENT | $228 | $228 | $228 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,247 | $1,247 | $1,247 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $36 | $36 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $179 | $179 | $179 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $302 | $302 | $302 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $131 | $131 | $131 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $364 | $364 | $364 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $15 | $15 | $15 |
| Emergency department visit low severity CPT 99282 • Emergency | $54 | $54 | $54 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $91 | $91 | $91 |
| Emergency department visit high severity CPT 99284 • Emergency | $155 | $155 | $155 |
| Emergency department visit highest severity CPT 99285 • Emergency | $225 | $225 | $225 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $349 | $349 | $349 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $153 | $153 | $153 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $512 | $512 | $512 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $473 | $473 | $473 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $629 | $629 | $629 |
| Esophageal motility study CPT 91010 • Gastroenterology | $221 | $221 | $221 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $470 | $470 | $470 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $416 | $416 | $416 |
| Auto-added CPT 00102 • General | $420 | $420 | $420 |
| Auto-added CPT 00104 • General | $300 | $300 | $300 |
| Auto-added CPT 00120 • General | $360 | $360 | $360 |
| Auto-added CPT 00124 • General | $300 | $300 | $300 |
| Auto-added CPT 00160 • General | $360 | $360 | $360 |
| Auto-added CPT 00170 • General | $360 | $360 | $360 |
| Auto-added CPT 00190 • General | $360 | $360 | $360 |