| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $0 | $0 | $0 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $88 | $145 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $30 | $30 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $114 | $114 | $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 | $48 | $48 | $48 |
| 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 | $41 | $48 | $55 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $510 | $595 | $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 | $197 | $197 | $198 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,647 | $1,922 | $2,197 |
| 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 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $147 | $147 | $147 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $30 | $30 |
| Nasal endoscopy with biopsy CPT 31237 • 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 | $28 | $30 |
| 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 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $30 | $30 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $29 | $29 | $29 |
| Tympanostomy tube insertion CPT 69436 • ENT | $141 | $141 | $141 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $414 | $797 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $944 | $944 | $944 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $30 | $30 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $30 | $30 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $23 | $26 | $30 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $247 | $247 | $247 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $30 | $30 |
| 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 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $30 | $30 | $30 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $13 | $21 | $30 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $143 | $143 | $143 |