| Nasal endoscopy with biopsy CPT 31237 • ENT | $897 | $897 | $897 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $1,088 | $1,088 | $1,088 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $1,625 | $1,625 | $1,625 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $775 | $775 | $775 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $1,278 | $1,278 | $1,278 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $2,063 | $2,063 | $2,063 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $176 | $176 | $176 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $569 | $569 | $569 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $611 | $611 | $611 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $601 | $601 | $601 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $388 | $388 | $388 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $43 | $43 | $43 |
| Tympanostomy tube insertion CPT 69436 • ENT | $472 | $472 | $472 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $2,438 | $2,438 | $2,438 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $2,810 | $2,810 | $2,810 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $59 | $59 | $59 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $97 | $97 | $97 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $258 | $258 | $258 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $138 | $138 | $138 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $147 | $147 | $147 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $147 | $147 | $147 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $158 | $158 | $158 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $201 | $201 | $201 |
| Initial treatment first degree burn CPT 16000 • Emergency | $71 | $71 | $71 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $58 | $58 | $58 |
| Emergency department visit low severity CPT 99282 • Emergency | $73 | $73 | $73 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $89 | $89 | $89 |
| Emergency department visit high severity CPT 99284 • Emergency | $124 | $124 | $124 |
| Emergency department visit highest severity CPT 99285 • Emergency | $172 | $172 | $172 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $252 | $252 | $252 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $120 | $120 | $120 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $459 | $459 | $459 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $525 | $525 | $525 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $674 | $674 | $674 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $390 | $390 | $390 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $673 | $673 | $673 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $586 | $586 | $586 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $856 | $856 | $856 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $1,425 | $1,425 | $1,425 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $1,557 | $1,557 | $1,557 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $589 | $589 | $589 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $620 | $620 | $620 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $218 | $218 | $218 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $830 | $830 | $830 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $1,140 | $1,140 | $1,140 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $1,006 | $1,006 | $1,006 |
| Esophageal motility study CPT 91010 • Gastroenterology | $155 | $155 | $155 |
| Auto-added CPT 10120 • General | $99 | $99 | $99 |
| Auto-added CPT 10140 • General | $112 | $112 | $112 |
| Auto-added CPT 11000 • General | $104 | $104 | $104 |