| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $75 | $75 | $75 |
| 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 | $99 | $99 | $99 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $17 | $17 | $17 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $53 | $53 | $53 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $5 | $5 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $131 | $131 | $131 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $59 | $59 | $59 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $69 | $69 | $69 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $62 | $62 | $62 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $33 | $33 | $33 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $1 | $1 | $1 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $24 | $24 | $24 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $19 | $19 | $19 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $25 | $25 | $25 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $7 | $7 | $7 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $26 | $26 | $26 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $31 | $31 | $31 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $33 | $33 | $33 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $98 | $98 | $98 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $915 | $915 | $915 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $112 | $112 | $112 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $327 | $327 | $327 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $145 | $145 | $145 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $97 | $97 | $97 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $58 | $58 | $58 |
| Septoplasty CPT 30520 • ENT | $353 | $353 | $353 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $80 | $80 | $80 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $33 | $33 | $33 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $201 | $201 | $201 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $341 | $341 | $341 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $250 | $250 | $250 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $93 | $93 | $93 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $137 | $137 | $137 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $292 | $292 | $292 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $45 | $45 | $45 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $96 | $96 | $96 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $160 | $160 | $160 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $85 | $85 | $85 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $71 | $71 | $71 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $11 | $11 | $11 |
| Tympanostomy tube insertion CPT 69436 • ENT | $84 | $84 | $84 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $293 | $293 | $293 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $346 | $346 | $346 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $19 | $19 | $19 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $42 | $42 | $42 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $70 | $70 | $70 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $23 | $23 | $23 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $46 | $46 | $46 |