| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $231 | $501 | $650 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $279 | $541 | $650 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $50 | $413 | $650 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $50 | $443 | $650 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $50 | $415 | $650 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $50 | $441 | $650 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $149 | $455 | $650 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $272 | $514 | $650 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $303 | $488 | $650 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $248 | $510 | $650 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $350 | $496 | $650 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $279 | $439 | $650 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $307 | $486 | $650 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $350 | $504 | $650 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $50 | $402 | $650 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $50 | $393 | $650 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $5 | $401 | $650 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $187 | $497 | $650 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $50 | $440 | $650 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $50 | $413 | $650 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $106 | $106 | $106 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $107 | $469 | $650 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $31 | $31 | $31 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $11 | $11 | $11 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $82 | $82 | $82 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $100 | $100 | $100 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $132 | $132 | $132 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $30 | $30 | $30 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $18 | $18 | $18 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $178 | $178 | $178 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $1,618 | $1,618 | $1,618 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $51 | $51 | $51 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $3,793 | $3,793 | $3,793 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $329 | $329 | $329 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $1,291 | $1,291 | $1,291 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $715 | $715 | $715 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $298 | $298 | $298 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $475 | $650 | $824 |
| Septoplasty CPT 30520 • ENT | $475 | $738 | $1,177 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $350 | $519 | $650 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $50 | $477 | $650 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $310 | $547 | $650 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $475 | $575 | $650 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $475 | $638 | $767 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $379 | $561 | $650 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $475 | $607 | $650 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $475 | $679 | $969 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $262 | $477 | $650 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $475 | $597 | $650 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $475 | $601 | $650 |