| Tonsillectomy primary under age 12 CPT 42826 • ENT | $44 | $44 | $44 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $44 | $44 | $44 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $21 | $33 | $44 |
| Tympanostomy tube insertion CPT 69436 • ENT | $71 | $71 | $71 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $568 | $568 | $568 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $669 | $669 | $669 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $6 | $6 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $48 | $48 | $48 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $44 | $119 | $194 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $86 | $86 | $86 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $51 | $77 | $103 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $47 | $47 | $47 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $101 | $101 | $101 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $186 | $186 | $186 |
| Initial treatment first degree burn CPT 16000 • Emergency | $10 | $27 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $9 | $9 | $9 |
| Emergency department visit low severity CPT 99282 • Emergency | $17 | $17 | $17 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $6 | $6 | $6 |
| Emergency department visit high severity CPT 99284 • Emergency | $154 | $154 | $154 |
| Emergency department visit highest severity CPT 99285 • Emergency | $14 | $14 | $14 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $226 | $226 | $226 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $9 | $9 | $9 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $16 | $16 | $16 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $258 | $258 | $258 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $15 | $15 | $15 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $44 | $133 | $221 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $81 | $81 | $81 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $21 | $21 | $21 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $25 | $135 | $246 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $24 | $24 | $24 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $341 | $341 | $341 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $189 | $189 | $189 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $44 | $166 | $289 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $245 | $367 | $489 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $16 | $188 | $359 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $91 | $91 | $91 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $6 | $6 | $6 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $193 | $194 | $195 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $212 | $212 | $212 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $32 | $38 | $44 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $112 | $112 | $112 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $202 | $202 | $202 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $108 | $108 | $108 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $214 | $1,603 | $2,992 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $176 | $176 | $176 |
| Esophageal motility study CPT 91010 • Gastroenterology | $177 | $177 | $177 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $76 | $290 | $505 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $394 | $421 | $448 |
| Auto-added CPT 00102 • General | $44 | $44 | $44 |
| Auto-added CPT 00104 • General | $44 | $44 | $44 |