| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $575 | $575 | $575 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $326 | $326 | $326 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $156 | $156 | $156 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $19 | $19 | $19 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $276 | $276 | $276 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $323 | $323 | $323 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $377 | $377 | $377 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $336 | $336 | $336 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $441 | $441 | $441 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $10 | $10 | $10 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $105 | $105 | $105 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $61 | $61 | $61 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $804 | $804 | $804 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $165 | $165 | $165 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $51 | $51 | $51 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $784 | $784 | $784 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $7,550 | $7,550 | $7,550 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $209 | $209 | $209 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,146 | $3,146 | $3,146 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $832 | $832 | $832 |
| Septoplasty CPT 30520 • ENT | $1,906 | $1,906 | $1,906 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $431 | $431 | $431 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $528 | $528 | $528 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $723 | $723 | $723 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $1,227 | $1,227 | $1,227 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $891 | $891 | $891 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $497 | $497 | $497 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $732 | $732 | $732 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $1,042 | $1,042 | $1,042 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $383 | $383 | $383 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $822 | $822 | $822 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $859 | $859 | $859 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $724 | $724 | $724 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $604 | $604 | $604 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $134 | $134 | $134 |
| Tympanostomy tube insertion CPT 69436 • ENT | $451 | $451 | $451 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $2,506 | $2,506 | $2,506 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $2,958 | $2,958 | $2,958 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $103 | $103 | $103 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $359 | $359 | $359 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $604 | $604 | $604 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $123 | $123 | $123 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $161 | $161 | $161 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $314 | $314 | $314 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $424 | $424 | $424 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $799 | $799 | $799 |
| Initial treatment first degree burn CPT 16000 • Emergency | $125 | $125 | $125 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $31 | $31 | $31 |
| Emergency department visit low severity CPT 99282 • Emergency | $115 | $115 | $115 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $196 | $196 | $196 |