| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $30 | $75 | $100 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $30 | $50 | $70 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $30 | $51 | $80 |
| 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 | $87 | $129 |
| Excision benign lesion trunk/arms/legs 1.1-2.0cm CPT 11402 • Dermatology | $146 | $146 | $146 |
| Excision benign lesion face 0.5cm or less CPT 11440 • Dermatology | $30 | $85 | $139 |
| Excision malignant lesion trunk/arms/legs 0.5cm or less CPT 11600 • Dermatology | $30 | $110 | $189 |
| 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 | $103 | $203 | $252 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $30 | $62 | $95 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $30 | $43 | $57 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $18 | $30 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $30 | $80 | $117 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $30 | $79 | $112 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $27 | $90 | $133 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $78 | $95 | $112 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $197 | $197 | $197 |
| Blood glucose test strip HCPCS A4253 • Durable Medical Equipment | $8 | $8 | $8 |
| Calibration solution glucose monitor HCPCS A4256 • Durable Medical Equipment | $4 | $4 | $5 |
| Crutches forearm each HCPCS E0110 • Durable Medical Equipment | $29 | $29 | $30 |
| Walker folding wheeled adjustable height HCPCS E0143 • Durable Medical Equipment | $53 | $63 | $73 |
| Hospital bed semi-electric HCPCS E0260 • Durable Medical Equipment | $512 | $512 | $512 |
| Portable gaseous oxygen system HCPCS E0431 • Durable Medical Equipment | $14 | $96 | $178 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $38 | $57 | $76 |
| Oxygen concentrator portable HCPCS E1390 • Durable Medical Equipment | $79 | $288 | $695 |
| Negative pressure wound therapy electric pump HCPCS E2402 • Durable Medical Equipment | $4,924 | $4,924 | $4,924 |
| Standard wheelchair HCPCS K0001 • Durable Medical Equipment | $174 | $222 | $270 |
| Power wheelchair group 2 standard HCPCS K0823 • Durable Medical Equipment | $304 | $1,178 | $2,052 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $134 | $134 | $134 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $543 | $543 | $543 |
| Knee orthosis adjustable joint HCPCS L1832 • Durable Medical Equipment | $221 | $221 | $221 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $108 | $167 | $285 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $259 | $488 |
| Septoplasty CPT 30520 • ENT | $697 | $697 | $697 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $150 | $150 | $150 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $136 | $212 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $242 | $366 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $320 | $320 | $320 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $250 | $469 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $231 | $231 | $231 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $211 | $392 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $339 | $339 | $339 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $118 | $206 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $30 | $36 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $155 | $182 | $206 |