| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $30 | $30 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.5cm or less CPT 11400 • Dermatology | $30 | $30 | $30 |
| Excision benign lesion trunk/arms/legs 0.6-1.0cm CPT 11401 • Dermatology | $30 | $66 | $102 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $133 | $133 | $133 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $30 | $30 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $112 | $193 |
| Excision malignant lesion trunk/arms/legs 0.6-1.0cm CPT 11601 • Dermatology | $143 | $143 | $143 |
| Excision malignant lesion trunk/arms/legs 1.1-2.0cm CPT 11602 • Dermatology | $30 | $134 | $237 |
| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $198 | $198 | $198 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $41 | $52 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $30 | $30 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $62 | $94 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $81 | $109 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $128 | $128 | $129 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $91 | $105 | $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 | $3 | $3 | $3 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $13 | $43 | $73 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $62 | $72 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $69 | $83 | $96 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $31 | $104 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $15 | $56 | $77 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $92 | $399 | $927 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $807 | $1,139 | $1,472 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $36 | $192 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $2,280 | $2,661 | $3,041 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $368 | $368 | $368 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $1,015 | $1,015 | $1,015 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $799 | $799 | $800 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $333 | $333 | $333 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $161 | $291 |
| Septoplasty CPT 30520 • ENT | $665 | $665 | $665 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $107 | $183 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $140 | $250 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $431 | $431 | $431 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $174 | $317 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $175 | $175 | $175 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $200 | $369 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $157 | $284 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $164 | $297 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $249 | $249 | $249 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $118 | $206 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $30 | $46 | $63 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $93 | $155 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |