| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $141 | $141 | $141 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $75 | $75 | $75 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $196 | $196 | $196 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $73 | $73 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $691 | $691 | $691 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $179 | $179 | $179 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $77 | $77 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $695 | $811 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,072 | $8,072 | $8,072 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $470 | $470 | $470 |
| Septoplasty CPT 30520 • ENT | $670 | $670 | $670 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $239 | $239 | $239 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $206 | $206 | $206 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $363 | $363 | $363 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $329 | $329 | $329 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $485 | $485 | $485 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $238 | $238 | $238 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $383 | $383 | $383 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $612 | $612 | $612 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $154 | $180 | $206 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $335 | $335 | $335 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $350 | $350 | $350 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $289 | $289 | $289 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $235 | $235 | $235 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $56 | $56 | $56 |
| Tympanostomy tube insertion CPT 69436 • ENT | $186 | $186 | $186 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $988 | $988 | $988 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,170 | $1,170 | $1,170 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $55 | $55 | $55 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $121 | $121 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $208 | $208 | $208 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $117 | $140 | $162 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $173 | $173 | $173 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $172 | $172 | $172 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $177 | $217 | $258 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $291 | $291 | $291 |
| Initial treatment first degree burn CPT 16000 • Emergency | $77 | $77 | $77 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $342 | $342 | $342 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $396 | $396 | $396 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $241 | $241 | $241 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $210 | $210 | $210 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $262 | $262 | $262 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $377 | $377 | $377 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $367 | $367 | $367 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $420 | $420 | $420 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $518 | $518 | $518 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $622 | $622 | $622 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $198 | $294 | $390 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $221 | $337 | $452 |