| Tonsillectomy primary under age 12 CPT 42826 • ENT | $58 | $58 | $58 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $36 | $36 | $36 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $33 | $33 | $33 |
| Tympanostomy tube insertion CPT 69436 • ENT | $33 | $33 | $33 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $93 | $93 | $93 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $220 | $220 | $220 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $14 | $14 | $14 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $25 | $25 | $25 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $137 | $137 | $137 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $34 | $34 | $34 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $29 | $29 | $29 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $55 | $55 | $55 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $133 | $133 | $133 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $57 | $57 | $57 |
| Initial treatment first degree burn CPT 16000 • Emergency | $12 | $12 | $12 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $1 | $1 | $1 |
| Emergency department visit low severity CPT 99282 • Emergency | $4 | $4 | $4 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $7 | $7 | $7 |
| Emergency department visit high severity CPT 99284 • Emergency | $83 | $83 | $83 |
| Emergency department visit highest severity CPT 99285 • Emergency | $136 | $136 | $136 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $19 | $19 | $19 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $55 | $55 | $55 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $175 | $175 | $175 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $49 | $49 | $49 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $431 | $431 | $431 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $29 | $29 | $29 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $187 | $187 | $187 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $425 | $425 | $425 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $38 | $38 | $38 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $25 | $25 | $25 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $35 | $35 | $35 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $196 | $196 | $196 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $300 | $300 | $300 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $101 | $101 | $101 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $17 | $17 | $17 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $94 | $94 | $94 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $21 | $21 | $21 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $204 | $204 | $204 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $99 | $99 | $99 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $505 | $505 | $505 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $84 | $84 | $84 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $52 | $52 | $52 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $525 | $525 | $525 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $284 | $284 | $284 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $73 | $73 | $73 |
| Esophageal motility study CPT 91010 • Gastroenterology | $156 | $156 | $156 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $363 | $363 | $363 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $58 | $58 | $58 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |