| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $0 | $0 | $0 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $57 | $83 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $30 | $72 | $114 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $110 | $110 | $110 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $5 | $5 | $5 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $12 | $27 | $42 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $40 | $40 | $40 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $503 | $503 | $503 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $130 | $130 | $130 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $55 | $55 | $55 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $680 | $680 | $681 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $5,868 | $5,868 | $5,868 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $19 | $108 | $198 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,647 | $1,922 | $2,197 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $467 | $467 | $467 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $384 | $384 | $384 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $178 | $178 | $178 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $30 | $30 |
| Septoplasty CPT 30520 • ENT | $30 | $30 | $30 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $30 | $30 | $30 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $30 | $30 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $172 | $172 | $172 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $25 | $25 | $25 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $30 | $30 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $30 | $30 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $414 | $797 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $487 | $944 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $30 | $30 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $94 | $158 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $51 | $51 | $51 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $23 | $126 | $229 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $30 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $35 | $39 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $59 | $59 | $59 |
| Emergency department visit low severity CPT 99282 • Emergency | $59 | $59 | $59 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $68 | $68 | $68 |
| Emergency department visit high severity CPT 99284 • Emergency | $124 | $124 | $124 |
| Emergency department visit highest severity CPT 99285 • Emergency | $180 | $180 | $180 |