| Tonsillectomy primary under age 12 CPT 42826 • ENT | $27 | $27 | $27 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $94 | $94 | $94 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $11 | $11 | $11 |
| Tympanostomy tube insertion CPT 69436 • ENT | $22 | $22 | $22 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $542 | $542 | $542 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $896 | $896 | $896 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $20 | $20 | $20 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $8 | $8 | $8 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $39 | $39 | $39 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $13 | $29 | $45 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $44 | $44 | $44 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $13 | $13 | $13 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $136 | $136 | $136 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $26 | $26 | $26 |
| Initial treatment first degree burn CPT 16000 • Emergency | $20 | $31 | $42 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $2 | $2 | $2 |
| Emergency department visit low severity CPT 99282 • Emergency | $61 | $61 | $61 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $5 | $5 | $5 |
| Emergency department visit high severity CPT 99284 • Emergency | $88 | $91 | $94 |
| Emergency department visit highest severity CPT 99285 • Emergency | $188 | $188 | $188 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $21 | $21 | $21 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $8 | $25 | $42 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $161 | $161 | $161 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $75 | $75 | $75 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $19 | $19 | $19 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $24 | $188 | $353 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $598 | $598 | $598 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $54 | $54 | $54 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $209 | $209 | $209 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $54 | $54 | $54 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $251 | $251 | $251 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $422 | $422 | $422 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $284 | $284 | $284 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $48 | $48 | $48 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $144 | $144 | $144 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $178 | $178 | $178 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $8 | $8 | $8 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $19 | $19 | $19 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $36 | $36 | $36 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $91 | $91 | $91 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $90 | $90 | $90 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $244 | $244 | $244 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $49 | $49 | $49 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $52 | $52 | $52 |
| Esophageal motility study CPT 91010 • Gastroenterology | $69 | $69 | $69 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $66 | $285 | $505 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $45 | $217 | $388 |
| Auto-added CPT 00102 • General | $40 | $40 | $40 |
| Auto-added CPT 00104 • General | $40 | $43 | $45 |