| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $30 | $30 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $30 | $30 | $30 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $30 | $30 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $30 | $30 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $36 | $36 | $36 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $121 | $121 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $30 | $30 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $30 | $30 | $30 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $30 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $74 | $74 | $74 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $76 | $76 | $76 |
| Emergency department visit low severity CPT 99282 • Emergency | $41 | $41 | $41 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $71 | $71 |
| Emergency department visit high severity CPT 99284 • Emergency | $120 | $120 | $120 |
| Emergency department visit highest severity CPT 99285 • Emergency | $190 | $190 | $190 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $30 | $30 | $30 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $30 | $30 | $30 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $150 | $150 | $150 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $30 | $30 | $30 |
| 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 | $227 | $227 | $227 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $30 | $30 | $30 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $30 | $30 | $30 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $30 | $30 | $30 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $30 | $30 | $30 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $452 | $452 | $452 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $156 | $156 | $156 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $411 | $411 | $411 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $30 | $30 | $30 |
| 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 | $2,502 | $2,502 | $2,502 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $324 | $324 | $324 |
| Esophageal motility study CPT 91010 • Gastroenterology | $30 | $30 | $30 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $464 | $464 | $464 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $410 | $410 | $410 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |
| Auto-added CPT 00120 • General | $30 | $30 | $30 |