| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $158 | $232 | $307 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $59 | $200 | $342 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $62 | $170 | $277 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $473 | $473 | $473 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $246 | $379 | $513 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $42 | $130 | $217 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $68 | $103 | $138 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $31 | $57 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $165 | $243 | $320 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $112 | $170 | $228 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $130 | $200 | $271 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $93 | $93 | $93 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $78 | $78 | $78 |
| 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 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $611 | $611 | $611 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $319 | $612 | $905 |
| Septoplasty CPT 30520 • ENT | $632 | $960 | $1,288 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $525 | $525 | $525 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $184 | $306 | $428 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $273 | $403 | $533 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $331 | $453 | $575 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $166 | $504 | $843 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $82 | $249 | $416 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $237 | $453 | $668 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $171 | $617 | $1,064 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $395 | $395 | $395 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $300 | $455 | $610 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $286 | $461 | $636 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $131 | $331 | $531 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $102 | $269 | $437 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $49 | $76 | $102 |
| Tympanostomy tube insertion CPT 69436 • ENT | $154 | $244 | $335 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,843 | $1,843 | $1,843 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $2,180 | $2,180 | $2,180 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $31 | $55 | $79 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $86 | $165 | $243 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $149 | $289 | $429 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $37 | $135 | $232 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $49 | $148 | $247 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $48 | $147 | $246 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $153 | $321 | $489 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $288 | $410 | $532 |
| Initial treatment first degree burn CPT 16000 • Emergency | $144 | $144 | $144 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $76 | $76 | $76 |
| Emergency department visit low severity CPT 99282 • Emergency | $41 | $64 | $87 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $101 | $131 |