| Tonsillectomy primary under age 12 CPT 42826 • ENT | $42 | $42 | $42 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $109 | $109 | $109 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $36 | $43 | $51 |
| Tympanostomy tube insertion CPT 69436 • ENT | $75 | $75 | $75 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $637 | $637 | $637 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $100 | $100 | $100 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $14 | $14 | $14 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $42 | $42 | $42 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $162 | $163 | $164 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $8 | $8 | $8 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $51 | $51 | $51 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $42 | $59 | $76 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $179 | $179 | $179 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $156 | $156 | $156 |
| Initial treatment first degree burn CPT 16000 • Emergency | $58 | $63 | $67 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $3 | $3 | $3 |
| Emergency department visit low severity CPT 99282 • Emergency | $3 | $31 | $58 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $9 | $9 | $9 |
| Emergency department visit high severity CPT 99284 • Emergency | $142 | $142 | $142 |
| Emergency department visit highest severity CPT 99285 • Emergency | $184 | $184 | $184 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $26 | $34 | $42 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $10 | $55 | $100 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $16 | $16 | $16 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $25 | $33 | $42 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $21 | $32 | $42 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $79 | $244 | $409 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $22 | $22 | $22 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $94 | $94 | $94 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $224 | $230 | $236 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $44 | $44 | $44 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $47 | $186 | $326 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $54 | $54 | $54 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $263 | $263 | $263 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $469 | $469 | $469 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $50 | $65 | $79 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $16 | $16 | $16 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $6 | $6 | $6 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $37 | $37 | $37 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $20 | $112 | $203 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $152 | $152 | $152 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $33 | $33 | $33 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $347 | $347 | $347 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $541 | $541 | $541 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $320 | $320 | $320 |
| Esophageal motility study CPT 91010 • Gastroenterology | $42 | $42 | $42 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $67 | $70 | $73 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $197 | $295 | $393 |
| Auto-added CPT 00102 • General | $42 | $42 | $42 |
| Auto-added CPT 00104 • General | $42 | $42 | $42 |