| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $106 | $342 | $795 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $48 | $309 | $795 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $42 | $268 | $795 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $42 | $254 | $795 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $67 | $317 | $795 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $39 | $302 | $795 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $73 | $317 | $795 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $67 | $332 | $795 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $100 | $335 | $795 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $91 | $327 | $795 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $169 | $383 | $795 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $94 | $362 | $795 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $138 | $325 | $795 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $110 | $287 | $795 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $80 | $324 | $795 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $35 | $293 | $795 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $2 | $266 | $795 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $87 | $319 | $795 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $42 | $235 | $795 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $72 | $256 | $795 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $103 | $215 | $424 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $45 | $332 | $795 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $6 | $8 | $11 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $6 | $43 | $67 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $4 | $14 | $35 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $45 | $198 | $492 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $13 | $99 | $165 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $6 | $20 | $43 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $549 | $611 | $720 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $75 | $2,058 | $5,165 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $22 | $123 | $181 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $208 | $1,402 | $2,051 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $212 | $232 | $254 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $593 | $653 | $742 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $330 | $353 | $393 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $154 | $186 | $221 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $178 | $409 | $795 |
| Septoplasty CPT 30520 • ENT | $430 | $777 | $1,306 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $129 | $385 | $795 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $163 | $413 | $795 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $228 | $470 | $795 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $276 | $729 | $1,470 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $203 | $424 | $795 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $113 | $354 | $795 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $226 | $722 | $1,470 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $322 | $741 | $1,470 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $165 | $417 | $795 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $254 | $497 | $795 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $194 | $615 | $1,205 |