| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $1,137 | $3,805 | $4,694 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $81 | $1,911 | $4,694 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $85 | $2,969 | $4,694 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $1,137 | $3,508 | $4,694 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $79 | $2,968 | $4,694 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $47 | $2,369 | $4,694 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $4 | $2,953 | $4,694 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $135 | $2,386 | $4,694 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $92 | $2,970 | $4,694 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $678 | $3,690 | $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 | $2,807 | $4,222 | $4,694 |
| Septoplasty CPT 30520 • ENT | $2,807 | $4,065 | $4,694 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $1,500 | $2,642 | $4,694 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $678 | $3,690 | $4,694 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $1,500 | $3,896 | $4,694 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $2,807 | $4,065 | $4,694 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $4,259 | $4,585 | $4,694 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $2,807 | $4,222 | $4,694 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $2,807 | $4,222 | $4,694 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $4,259 | $4,585 | $4,694 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $678 | $3,690 | $4,694 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $2,807 | $4,222 | $4,694 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $2,807 | $3,985 | $4,694 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $2,807 | $4,065 | $4,694 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $2,807 | $4,222 | $4,694 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $34 | $2,525 | $4,694 |
| Tympanostomy tube insertion CPT 69436 • ENT | $1,500 | $3,896 | $4,694 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $4,694 | $5,118 | $6,391 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $4,694 | $5,118 | $6,391 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $89 | $2,970 | $4,694 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $147 | $2,981 | $4,694 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $678 | $3,690 | $4,694 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $678 | $3,355 | $4,694 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $678 | $3,355 | $4,694 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $184 | $2,396 | $4,694 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $239 | $3,000 | $4,694 |
| Initial treatment first degree burn CPT 16000 • Emergency | $678 | $678 | $678 |
| 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 |