| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $66 | $66 | $66 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $110 | $110 | $110 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $103 | $115 | $128 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $112 | $112 | $112 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $152 | $152 | $152 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $2 | $2 | $2 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $45 | $53 | $61 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $53 | $53 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $461 | $461 | $461 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $178 | $178 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $51 | $51 | $51 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $619 | $619 | $619 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $8,071 | $8,071 | $8,071 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $27 | $27 | $27 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,708 | $2,875 | $3,041 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $368 | $368 | $368 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $410 | $410 | $411 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $171 | $252 | $333 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $271 | $281 | $291 |
| Septoplasty CPT 30520 • ENT | $665 | $665 | $665 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $215 | $215 | $215 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $183 | $183 | $183 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $250 | $250 | $250 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $431 | $431 | $431 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $317 | $317 | $317 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $165 | $165 | $165 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $369 | $369 | $369 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $174 | $174 | $174 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $284 | $284 | $284 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $297 | $297 | $297 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $249 | $249 | $249 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $206 | $206 | $206 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $32 | $32 | $32 |
| Tympanostomy tube insertion CPT 69436 • ENT | $138 | $147 | $155 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $877 | $877 | $877 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $937 | $987 | $1,037 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $36 | $36 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $121 | $124 | $127 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $178 | $178 | $178 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $110 | $110 | $110 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $54 | $54 | $54 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $205 | $205 | $205 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $220 | $249 | $277 |
| Initial treatment first degree burn CPT 16000 • Emergency | $44 | $51 | $58 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $76 | $76 | $76 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $77 | $77 | $77 |
| Emergency department visit high severity CPT 99284 • Emergency | $120 | $136 | $152 |
| Emergency department visit highest severity CPT 99285 • Emergency | $190 | $190 | $190 |