| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $53 | $53 | $53 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $41 | $41 | $41 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $24 | $24 | $24 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $3 | $3 | $3 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $75 | $75 | $75 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $29 | $29 | $29 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $55 | $55 | $55 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $29 | $29 | $29 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $30 | $30 | $30 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $6 | $6 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $54 | $54 | $54 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $40 | $40 | $40 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $72 | $72 | $72 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $21 | $21 | $21 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $41 | $41 | $41 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $2,188 | $2,188 | $2,188 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $852 | $852 | $852 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $28 | $28 | $28 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $316 | $316 | $316 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $243 | $243 | $243 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $735 | $735 | $735 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $399 | $399 | $399 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $197 | $197 | $197 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $183 | $183 | $183 |
| Septoplasty CPT 30520 • ENT | $263 | $263 | $263 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $94 | $94 | $94 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $80 | $80 | $80 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $82 | $82 | $82 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $124 | $124 | $124 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $182 | $182 | $182 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $89 | $89 | $89 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $144 | $144 | $144 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $230 | $230 | $230 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $60 | $60 | $60 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $129 | $129 | $129 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $135 | $135 | $135 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $112 | $112 | $112 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $91 | $91 | $91 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $14 | $14 | $14 |
| Tympanostomy tube insertion CPT 69436 • ENT | $71 | $71 | $71 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $383 | $383 | $383 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $453 | $453 | $453 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $17 | $17 | $17 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $47 | $47 | $47 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $70 | $70 | $70 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $64 | $64 | $64 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $68 | $68 | $68 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $68 | $68 | $68 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $102 | $102 | $102 |