| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $81 | $2,387 | $4,694 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $85 | $2,389 | $4,694 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $4,694 | $4,694 | $4,694 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $79 | $2,386 | $4,694 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $47 | $2,371 | $4,694 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $4 | $2,349 | $4,694 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $135 | $2,415 | $4,694 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $92 | $2,393 | $4,694 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $4,694 | $4,694 | $4,694 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $79 | $79 | $79 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $4,694 | $4,694 | $4,694 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $78 | $78 | $78 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $33 | $33 | $33 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $121 | $121 | $121 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $39 | $39 | $39 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $1,426 | $1,426 | $1,426 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $4,694 | $4,694 | $4,694 |
| Septoplasty CPT 30520 • ENT | $4,694 | $4,694 | $4,694 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $4,694 | $4,694 | $4,694 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $4,694 | $4,694 | $4,694 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $4,694 | $4,694 | $4,694 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $4,694 | $4,694 | $4,694 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $4,694 | $4,694 | $4,694 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $4,694 | $4,694 | $4,694 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $4,694 | $4,694 | $4,694 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $34 | $2,364 | $4,694 |
| Tympanostomy tube insertion CPT 69436 • ENT | $4,694 | $4,694 | $4,694 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $4,694 | $4,694 | $4,694 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $4,694 | $4,694 | $4,694 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $89 | $2,391 | $4,694 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $147 | $2,421 | $4,694 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $4,694 | $4,694 | $4,694 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $4,694 | $4,694 | $4,694 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $4,694 | $4,694 | $4,694 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $184 | $2,439 | $4,694 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $239 | $2,467 | $4,694 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $9 | $9 | $9 |
| Emergency department visit low severity CPT 99282 • Emergency | $33 | $33 | $33 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $56 | $56 | $56 |
| Emergency department visit high severity CPT 99284 • Emergency | $97 | $97 | $97 |
| Emergency department visit highest severity CPT 99285 • Emergency | $141 | $141 | $141 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $277 | $277 | $277 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $99 | $99 | $99 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $4,694 | $4,694 | $4,694 |