| Tonsillectomy primary under age 12 CPT 42826 • ENT | $42 | $42 | $42 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $145 | $145 | $145 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $28 | $28 | $28 |
| Tympanostomy tube insertion CPT 69436 • ENT | $15 | $15 | $15 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $85 | $85 | $85 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $44 | $44 | $44 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $38 | $38 | $38 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $12 | $12 | $12 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $140 | $167 | $194 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $13 | $13 | $13 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $5 | $5 | $5 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $5 | $5 | $5 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $49 | $49 | $49 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $22 | $22 | $22 |
| Initial treatment first degree burn CPT 16000 • Emergency | $12 | $28 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $3 | $3 | $3 |
| Emergency department visit low severity CPT 99282 • Emergency | $34 | $46 | $58 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $71 | $71 |
| Emergency department visit high severity CPT 99284 • Emergency | $95 | $95 | $96 |
| Emergency department visit highest severity CPT 99285 • Emergency | $141 | $141 | $141 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $26 | $26 | $26 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $10 | $10 | $10 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $74 | $74 | $74 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $172 | $172 | $172 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $73 | $73 | $73 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $39 | $42 | $44 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $197 | $197 | $197 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $290 | $290 | $290 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $246 | $246 | $246 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $36 | $36 | $36 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $44 | $193 | $341 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $344 | $344 | $344 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $44 | $51 | $58 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $445 | $467 | $489 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $72 | $118 | $164 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $33 | $254 | $476 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $12 | $12 | $12 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $39 | $125 | $212 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $75 | $75 | $75 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $46 | $282 | $517 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $152 | $152 | $152 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $395 | $395 | $395 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $160 | $160 | $160 |
| Esophageal motility study CPT 91010 • Gastroenterology | $127 | $127 | $127 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $61 | $70 | $79 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $90 | $90 | $90 |
| Auto-added CPT 00102 • General | $44 | $47 | $50 |
| Auto-added CPT 00104 • General | $44 | $44 | $44 |