| Tonsillectomy primary under age 12 CPT 42826 • ENT | $25 | $25 | $25 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $163 | $163 | $163 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $3 | $3 | $3 |
| Tympanostomy tube insertion CPT 69436 • ENT | $124 | $124 | $124 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $148 | $148 | $148 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $200 | $200 | $200 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $7 | $7 | $7 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $44 | $44 | $44 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $115 | $115 | $115 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $50 | $50 | $50 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $25 | $25 | $25 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $51 | $51 | $51 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $55 | $55 | $55 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $15 | $15 | $15 |
| Initial treatment first degree burn CPT 16000 • Emergency | $10 | $37 | $63 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $69 | $69 | $69 |
| Emergency department visit low severity CPT 99282 • Emergency | $31 | $32 | $33 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $28 | $28 | $28 |
| Emergency department visit high severity CPT 99284 • Emergency | $12 | $64 | $116 |
| Emergency department visit highest severity CPT 99285 • Emergency | $164 | $164 | $164 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $26 | $26 | $26 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $44 | $70 | $96 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $25 | $25 | $25 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $45 | $45 | $45 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $391 | $391 | $391 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $19 | $207 | $395 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $15 | $15 | $15 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $435 | $435 | $435 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $37 | $37 | $37 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $30 | $30 | $30 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $44 | $161 | $278 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $57 | $57 | $57 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $180 | $180 | $180 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $91 | $91 | $91 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $48 | $204 | $359 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $320 | $320 | $320 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $32 | $32 | $32 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $386 | $386 | $386 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $99 | $99 | $99 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $77 | $77 | $77 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $70 | $70 | $70 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $182 | $182 | $182 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $285 | $312 | $340 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $57 | $57 | $57 |
| Esophageal motility study CPT 91010 • Gastroenterology | $172 | $172 | $172 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $77 | $251 | $425 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $55 | $145 | $235 |
| Auto-added CPT 00102 • General | $30 | $37 | $44 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |