| Tonsillectomy primary under age 12 CPT 42826 • ENT | $28 | $28 | $28 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $162 | $162 | $162 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $4 | $4 | $4 |
| Tympanostomy tube insertion CPT 69436 • ENT | $14 | $14 | $14 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $568 | $568 | $568 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $478 | $478 | $478 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $32 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $23 | $23 | $23 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $39 | $39 | $39 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $19 | $29 | $38 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $25 | $25 | $25 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $7 | $7 | $7 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $134 | $191 | $247 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $75 | $75 | $75 |
| Initial treatment first degree burn CPT 16000 • Emergency | $7 | $25 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $17 | $17 | $17 |
| Emergency department visit low severity CPT 99282 • Emergency | $17 | $47 | $78 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $121 | $121 | $121 |
| Emergency department visit high severity CPT 99284 • Emergency | $10 | $10 | $10 |
| Emergency department visit highest severity CPT 99285 • Emergency | $14 | $14 | $14 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $17 | $17 | $17 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $10 | $27 | $44 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $123 | $123 | $123 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $34 | $34 | $34 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $44 | $44 | $44 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $37 | $41 | $44 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $657 | $657 | $657 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $116 | $116 | $116 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $185 | $215 | $246 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $239 | $239 | $239 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $34 | $39 | $44 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $189 | $189 | $189 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $289 | $289 | $289 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $367 | $367 | $367 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $44 | $63 | $82 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $477 | $477 | $477 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $9 | $9 | $9 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $39 | $213 | $386 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $42 | $42 | $42 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $256 | $256 | $256 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $421 | $421 | $421 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $40 | $40 | $40 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $22 | $22 | $22 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $299 | $299 | $299 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $176 | $176 | $176 |
| Esophageal motility study CPT 91010 • Gastroenterology | $237 | $237 | $237 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $80 | $292 | $505 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $90 | $241 | $393 |
| Auto-added CPT 00102 • General | $44 | $44 | $44 |
| Auto-added CPT 00104 • General | $44 | $44 | $44 |