| Tonsillectomy primary under age 12 CPT 42826 • ENT | $304 | $304 | $304 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $29 | $29 | $29 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $15 | $15 | $15 |
| Tympanostomy tube insertion CPT 69436 • ENT | $106 | $106 | $106 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $439 | $439 | $439 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $34 | $34 | $34 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $47 | $47 | $47 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $77 | $77 | $77 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $208 | $208 | $208 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $16 | $16 | $16 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $7 | $7 | $7 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $95 | $95 | $95 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $60 | $60 | $60 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $207 | $207 | $207 |
| Initial treatment first degree burn CPT 16000 • Emergency | $8 | $8 | $8 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $1 | $6 | $11 |
| Emergency department visit low severity CPT 99282 • Emergency | $3 | $18 | $33 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $31 | $58 | $86 |
| Emergency department visit high severity CPT 99284 • Emergency | $56 | $82 | $108 |
| Emergency department visit highest severity CPT 99285 • Emergency | $22 | $90 | $158 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $34 | $34 | $34 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $17 | $17 | $17 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $77 | $77 | $77 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $28 | $28 | $28 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $27 | $27 | $27 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $86 | $86 | $86 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $132 | $132 | $132 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $510 | $510 | $510 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $23 | $23 | $23 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $50 | $50 | $50 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $63 | $63 | $63 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $61 | $61 | $61 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $73 | $73 | $73 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $95 | $95 | $95 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $33 | $33 | $33 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $34 | $34 | $34 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $55 | $55 | $55 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $163 | $163 | $163 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $142 | $142 | $142 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $63 | $63 | $63 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $51 | $51 | $51 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $48 | $48 | $48 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $41 | $41 | $41 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $452 | $452 | $452 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $95 | $95 | $95 |
| Esophageal motility study CPT 91010 • Gastroenterology | $43 | $43 | $43 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $346 | $346 | $346 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $62 | $62 | $62 |
| Auto-added CPT 00102 • General | $34 | $34 | $34 |
| Auto-added CPT 00104 • General | $48 | $48 | $48 |