| Tonsillectomy primary under age 12 CPT 42826 • ENT | $187 | $187 | $187 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $41 | $41 | $41 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $4 | $4 | $4 |
| Tympanostomy tube insertion CPT 69436 • ENT | $28 | $28 | $28 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $116 | $446 | $775 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $92 | $92 | $92 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $36 | $36 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $21 | $21 | $21 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $133 | $133 | $133 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $39 | $39 | $39 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $14 | $14 | $14 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $94 | $94 | $94 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $19 | $117 | $215 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $14 | $14 | $14 |
| Initial treatment first degree burn CPT 16000 • Emergency | $10 | $10 | $10 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $9 | $9 | $10 |
| Emergency department visit low severity CPT 99282 • Emergency | $3 | $20 | $34 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $5 | $37 | $69 |
| Emergency department visit high severity CPT 99284 • Emergency | $13 | $64 | $115 |
| Emergency department visit highest severity CPT 99285 • Emergency | $126 | $126 | $127 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $152 | $152 | $152 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $11 | $44 | $76 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $23 | $23 | $23 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $204 | $204 | $204 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $266 | $266 | $266 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $73 | $218 | $363 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $70 | $70 | $70 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $169 | $197 | $225 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $217 | $217 | $217 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $31 | $171 | $310 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $52 | $52 | $52 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $35 | $35 | $35 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $447 | $447 | $447 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $60 | $60 | $60 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $166 | $278 | $389 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $26 | $26 | $26 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $36 | $107 | $178 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $411 | $411 | $411 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $63 | $63 | $63 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $70 | $70 | $70 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $246 | $246 | $246 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $115 | $115 | $115 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $227 | $227 | $227 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $241 | $241 | $241 |
| Esophageal motility study CPT 91010 • Gastroenterology | $42 | $42 | $42 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $43 | $197 | $351 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $53 | $53 | $53 |
| Auto-added CPT 00102 • General | $45 | $45 | $45 |
| Auto-added CPT 00104 • General | $45 | $45 | $45 |