| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $308 | $308 | $308 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $174 | $174 | $174 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $17 | $17 | $17 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $435 | $435 | $435 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $297 | $297 | $297 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $349 | $349 | $349 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $306 | $306 | $306 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $423 | $423 | $423 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $783 | $783 | $783 |
| Septoplasty CPT 30520 • ENT | $1,780 | $1,780 | $1,780 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $593 | $593 | $593 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $516 | $516 | $516 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $676 | $676 | $676 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $1,158 | $1,158 | $1,158 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $856 | $856 | $856 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $477 | $477 | $477 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $702 | $702 | $702 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $1,001 | $1,001 | $1,001 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $513 | $513 | $513 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $766 | $766 | $766 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $800 | $800 | $800 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $668 | $668 | $668 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $552 | $552 | $552 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $126 | $126 | $126 |
| Tympanostomy tube insertion CPT 69436 • ENT | $417 | $417 | $417 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $2,397 | $2,397 | $2,397 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $2,824 | $2,824 | $2,824 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $102 | $102 | $102 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $326 | $326 | $326 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $560 | $560 | $560 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $247 | $247 | $247 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $300 | $300 | $300 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $299 | $299 | $299 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $697 | $697 | $697 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $750 | $750 | $750 |
| Initial treatment first degree burn CPT 16000 • Emergency | $197 | $197 | $197 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $52 | $52 | $52 |
| Emergency department visit low severity CPT 99282 • Emergency | $101 | $101 | $101 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $153 | $153 | $153 |
| Emergency department visit high severity CPT 99284 • Emergency | $291 | $291 | $291 |
| Emergency department visit highest severity CPT 99285 • Emergency | $430 | $430 | $430 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $594 | $594 | $594 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $261 | $261 | $261 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $410 | $410 | $410 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $798 | $798 | $798 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $1,160 | $1,160 | $1,160 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $1,039 | $1,039 | $1,039 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $3,049 | $3,049 | $3,049 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $1,353 | $1,353 | $1,353 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $618 | $618 | $618 |