| Tonsillectomy primary under age 12 CPT 42826 • ENT | $59 | $59 | $59 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $121 | $121 | $121 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $42 | $42 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $105 | $105 | $105 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $619 | $619 | $619 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $42 | $42 | $42 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $32 | $32 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $10 | $10 | $10 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $107 | $107 | $107 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $76 | $76 | $76 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $19 | $19 | $19 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $24 | $24 | $24 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $20 | $20 | $20 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $222 | $222 | $222 |
| Initial treatment first degree burn CPT 16000 • Emergency | $20 | $20 | $20 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $64 | $64 | $64 |
| Emergency department visit low severity CPT 99282 • Emergency | $5 | $5 | $5 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $46 | $46 | $46 |
| Emergency department visit high severity CPT 99284 • Emergency | $44 | $44 | $44 |
| Emergency department visit highest severity CPT 99285 • Emergency | $207 | $207 | $207 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $17 | $17 | $17 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $46 | $46 | $46 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $90 | $90 | $90 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $53 | $53 | $53 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $340 | $340 | $340 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $356 | $356 | $356 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $28 | $28 | $28 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $235 | $235 | $235 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $42 | $42 | $42 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $42 | $42 | $42 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $57 | $57 | $57 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $422 | $422 | $422 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $430 | $430 | $430 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $55 | $55 | $55 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $303 | $303 | $303 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $104 | $104 | $104 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $33 | $33 | $33 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $216 | $216 | $216 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $80 | $80 | $80 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $24 | $24 | $24 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $274 | $274 | $274 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $304 | $304 | $304 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $112 | $112 | $112 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $48 | $48 | $48 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $40 | $40 | $40 |
| Esophageal motility study CPT 91010 • Gastroenterology | $97 | $97 | $97 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $427 | $427 | $427 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $400 | $400 | $400 |
| Auto-added CPT 00102 • General | $42 | $42 | $42 |
| Auto-added CPT 00104 • General | $42 | $42 | $42 |