| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $41 | $121 | $200 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $99 | $99 | $99 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $41 | $41 | $41 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $91 | $91 | $91 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $41 | $74 | $107 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $65 | $65 | $65 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $161 | $161 | $161 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $10 | $10 | $10 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $5 | $5 | $5 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $6 | $20 | $33 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $44 | $44 | $44 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $512 | $512 | $512 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $143 | $143 | $143 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $5 | $5 | $5 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $89 | $89 | $89 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $6,331 | $6,331 | $6,331 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $232 | $232 | $232 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,226 | $2,226 | $2,226 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $250 | $250 | $250 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $791 | $791 | $791 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $41 | $41 | $41 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $203 | $203 | $203 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $41 | $199 | $357 |
| Septoplasty CPT 30520 • ENT | $499 | $499 | $499 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $158 | $158 | $158 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $266 | $266 | $266 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $221 | $221 | $221 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $324 | $324 | $324 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $41 | $41 | $41 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $41 | $41 | $41 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $41 | $41 | $41 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $249 | $249 | $249 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $259 | $259 | $259 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $216 | $216 | $216 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $179 | $179 | $179 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $41 | $41 | $41 |
| Tympanostomy tube insertion CPT 69436 • ENT | $139 | $139 | $139 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $41 | $468 | $894 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $36 | $36 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $89 | $89 | $89 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $94 | $94 | $94 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $41 | $41 | $41 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $41 | $130 | $218 |
| Initial treatment first degree burn CPT 16000 • Emergency | $41 | $41 | $41 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $66 | $66 | $66 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $67 | $67 | $67 |
| Emergency department visit high severity CPT 99284 • Emergency | $132 | $132 | $132 |
| Emergency department visit highest severity CPT 99285 • Emergency | $179 | $179 | $179 |