| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $160 | $160 | $160 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $75 | $75 | $75 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $45 | $60 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $15 | $22 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $121 | $213 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $46 | $61 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $79 | $79 | $79 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $24 | $24 | $24 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $156 | $156 | $156 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $15 | $15 | $15 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $12 | $12 | $12 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $96 | $96 | $96 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $24 | $24 | $24 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $12 | $12 | $12 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $133 | $133 | $133 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $37 | $37 | $37 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $420 | $420 | $420 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $322 | $322 | $322 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $977 | $977 | $977 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $699 | $699 | $699 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $291 | $291 | $291 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $307 | $307 | $307 |
| Septoplasty CPT 30520 • ENT | $475 | $475 | $475 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $123 | $123 | $123 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $117 | $117 | $117 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $251 | $251 | $251 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $331 | $331 | $331 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $494 | $494 | $494 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $235 | $235 | $235 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $380 | $380 | $380 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $596 | $596 | $596 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $168 | $168 | $168 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $313 | $313 | $313 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $345 | $345 | $345 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $288 | $288 | $288 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $195 | $195 | $195 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $65 | $65 | $65 |
| Tympanostomy tube insertion CPT 69436 • ENT | $164 | $164 | $164 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $798 | $798 | $798 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $974 | $974 | $974 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $41 | $41 | $41 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $92 | $92 | $92 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $167 | $167 | $167 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $146 | $146 | $146 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $158 | $158 | $158 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $153 | $153 | $153 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $30 | $105 | $180 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $204 | $204 | $204 |