| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $123 | $123 | $123 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $104 | $104 | $104 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $53 | $59 | $65 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $7 | $8 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $96 | $96 | $96 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $108 | $125 | $143 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $82 | $124 | $167 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $105 | $105 | $105 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $128 | $128 | $128 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $7 | $7 | $7 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $15 | $15 | $15 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $13 | $13 | $13 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $12 | $12 | $12 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $1,042 | $1,042 | $1,042 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $311 | $311 | $311 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $164 | $164 | $164 |
| Septoplasty CPT 30520 • ENT | $614 | $614 | $614 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $136 | $136 | $136 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $59 | $59 | $59 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $148 | $148 | $148 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $398 | $398 | $398 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $296 | $296 | $296 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $166 | $166 | $166 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $243 | $243 | $243 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $346 | $346 | $346 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $175 | $175 | $175 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $271 | $271 | $271 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $283 | $283 | $283 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $238 | $238 | $238 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $199 | $199 | $199 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $36 | $36 | $36 |
| Tympanostomy tube insertion CPT 69436 • ENT | $148 | $148 | $148 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $809 | $809 | $809 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $958 | $958 | $958 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $36 | $36 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $117 | $117 | $117 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $196 | $196 | $196 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $43 | $43 | $43 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $109 | $109 | $109 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $53 | $53 | $53 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $249 | $249 | $249 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $268 | $268 | $268 |
| Initial treatment first degree burn CPT 16000 • Emergency | $84 | $84 | $84 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $12 | $12 | $12 |
| Emergency department visit low severity CPT 99282 • Emergency | $43 | $43 | $43 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $72 | $72 | $72 |
| Emergency department visit high severity CPT 99284 • Emergency | $123 | $123 | $123 |
| Emergency department visit highest severity CPT 99285 • Emergency | $179 | $179 | $179 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $217 | $217 | $217 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $109 | $109 | $109 |