| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $82 | $82 | $82 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $111 | $111 | $111 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $7 | $7 | $7 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $245 | $245 | $245 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $97 | $97 | $97 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $121 | $121 | $121 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $92 | $92 | $92 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $101 | $101 | $101 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $600 | $600 | $600 |
| Septoplasty CPT 30520 • ENT | $866 | $866 | $866 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $186 | $186 | $186 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $261 | $261 | $261 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $457 | $457 | $457 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $411 | $411 | $411 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $605 | $605 | $605 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $297 | $297 | $297 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $479 | $479 | $479 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $763 | $763 | $763 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $263 | $263 | $263 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $428 | $428 | $428 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $445 | $445 | $445 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $369 | $369 | $369 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $301 | $301 | $301 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $71 | $71 | $71 |
| Tympanostomy tube insertion CPT 69436 • ENT | $235 | $235 | $235 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,259 | $1,259 | $1,259 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,490 | $1,490 | $1,490 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $58 | $58 | $58 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $132 | $132 | $132 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $262 | $262 | $262 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $152 | $152 | $152 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $223 | $223 | $223 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $156 | $156 | $156 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $332 | $332 | $332 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $260 | $260 | $260 |
| Initial treatment first degree burn CPT 16000 • Emergency | $69 | $69 | $69 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $32 | $32 | $32 |
| Emergency department visit low severity CPT 99282 • Emergency | $63 | $63 | $63 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $96 | $96 | $96 |
| Emergency department visit high severity CPT 99284 • Emergency | $180 | $180 | $180 |
| Emergency department visit highest severity CPT 99285 • Emergency | $266 | $266 | $266 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $335 | $335 | $335 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $167 | $167 | $167 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $199 | $199 | $199 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $218 | $218 | $218 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $259 | $259 | $259 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $302 | $302 | $302 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $263 | $263 | $263 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $328 | $328 | $328 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $477 | $477 | $477 |