| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $80 | $80 | $80 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $80 | $80 | $80 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $80 | $80 | $80 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $70 | $70 | $70 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $80 | $80 | $80 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $80 | $80 | $80 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $113 | $113 | $113 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $80 | $80 | $80 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $70 | $70 | $70 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $179 | $179 | $179 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $80 | $80 | $80 |
| 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 | $80 | $80 | $80 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $80 | $80 | $80 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $80 | $80 | $80 |
| 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 | $80 | $80 | $80 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $80 | $80 | $80 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $291 | $291 | $291 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $80 | $80 | $80 |
| Septoplasty CPT 30520 • ENT | $80 | $80 | $80 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $291 | $291 | $291 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $295 | $295 | $295 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $430 | $430 | $430 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $296 | $296 | $296 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $80 | $80 | $80 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $184 | $184 | $184 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $350 | $350 | $350 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $80 | $80 | $80 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $270 | $270 | $270 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $472 | $472 | $472 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $80 | $80 | $80 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $80 | $80 | $80 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $336 | $336 | $336 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $68 | $68 | $68 |
| Tympanostomy tube insertion CPT 69436 • ENT | $202 | $202 | $202 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $80 | $80 | $80 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $80 | $80 | $80 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $80 | $80 | $80 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $149 | $149 | $149 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $80 | $80 | $80 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $80 | $80 | $80 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $80 | $80 | $80 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $80 | $80 | $80 |