| Tonsillectomy primary under age 12 CPT 42826 • ENT | $21 | $21 | $21 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $83 | $83 | $83 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $6 | $23 | $40 |
| Tympanostomy tube insertion CPT 69436 • ENT | $130 | $130 | $130 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $40 | $281 | $523 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $578 | $578 | $578 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $16 | $16 | $16 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $40 | $40 | $40 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $40 | $93 | $145 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $117 | $117 | $118 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $13 | $54 | $95 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $125 | $125 | $125 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $26 | $26 | $26 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $31 | $31 | $31 |
| Initial treatment first degree burn CPT 16000 • Emergency | $8 | $8 | $8 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $2 | $2 | $2 |
| Emergency department visit low severity CPT 99282 • Emergency | $5 | $27 | $49 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $53 | $53 | $53 |
| Emergency department visit high severity CPT 99284 • Emergency | $15 | $60 | $106 |
| Emergency department visit highest severity CPT 99285 • Emergency | $15 | $15 | $15 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $33 | $33 | $33 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $10 | $54 | $98 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $17 | $17 | $17 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $61 | $61 | $61 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $54 | $54 | $54 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $34 | $103 | $171 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $37 | $37 | $37 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $202 | $202 | $202 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $52 | $52 | $52 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $223 | $259 | $296 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $73 | $73 | $73 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $40 | $40 | $40 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $217 | $326 | $434 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $40 | $88 | $136 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $118 | $137 | $157 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $5 | $5 | $5 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $313 | $313 | $313 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $40 | $131 | $221 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $31 | $120 | $209 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $74 | $74 | $74 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $422 | $422 | $423 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $23 | $23 | $23 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $214 | $214 | $214 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $354 | $354 | $354 |
| Esophageal motility study CPT 91010 • Gastroenterology | $29 | $29 | $29 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $36 | $36 | $36 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $60 | $85 | $110 |
| Auto-added CPT 00102 • General | $40 | $40 | $40 |
| Auto-added CPT 00104 • General | $40 | $40 | $40 |