| Tonsillectomy primary under age 12 CPT 42826 • ENT | $36 | $36 | $36 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $196 | $196 | $196 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $29 | $35 | $41 |
| Tympanostomy tube insertion CPT 69436 • ENT | $99 | $99 | $99 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $559 | $678 | $797 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $944 | $944 | $944 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $7 | $7 | $7 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $81 | $81 | $81 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $139 | $161 | $184 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $98 | $98 | $98 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $5 | $5 | $5 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $65 | $65 | $65 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $22 | $22 | $22 |
| Initial treatment first degree burn CPT 16000 • Emergency | $20 | $25 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $9 | $9 | $9 |
| Emergency department visit low severity CPT 99282 • Emergency | $33 | $33 | $34 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $68 | $68 | $68 |
| Emergency department visit high severity CPT 99284 • Emergency | $105 | $105 | $105 |
| Emergency department visit highest severity CPT 99285 • Emergency | $180 | $180 | $180 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $17 | $17 | $17 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $86 | $86 | $86 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $107 | $107 | $107 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $42 | $42 | $42 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $64 | $64 | $64 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $123 | $244 | $364 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $32 | $32 | $32 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $209 | $209 | $209 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $298 | $298 | $299 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $50 | $50 | $50 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $168 | $168 | $168 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $214 | $321 | $428 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $108 | $203 | $298 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $196 | $196 | $196 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $26 | $26 | $26 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $17 | $89 | $160 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $83 | $247 | $412 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $84 | $135 | $185 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $42 | $42 | $42 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $250 | $250 | $250 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $62 | $62 | $62 |
| Esophageal motility study CPT 91010 • Gastroenterology | $162 | $162 | $162 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $228 | $302 | $377 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $402 | $402 | $403 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |