| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $103 | $103 | $103 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $53 | $53 | $53 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $12 | $12 | $12 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $206 | $206 | $206 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $103 | $103 | $103 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $118 | $118 | $118 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $41 | $41 | $41 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $74 | $74 | $74 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $444 | $444 | $444 |
| Septoplasty CPT 30520 • ENT | $576 | $576 | $576 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $139 | $139 | $139 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $203 | $203 | $203 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $232 | $232 | $232 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $358 | $358 | $358 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $531 | $531 | $531 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $259 | $259 | $259 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $419 | $419 | $419 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $671 | $671 | $671 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $155 | $155 | $155 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $338 | $338 | $338 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $367 | $367 | $367 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $301 | $301 | $301 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $240 | $240 | $240 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $40 | $40 | $40 |
| Tympanostomy tube insertion CPT 69436 • ENT | $199 | $199 | $199 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $982 | $982 | $982 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,174 | $1,174 | $1,174 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $51 | $51 | $51 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $112 | $112 | $112 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $201 | $201 | $201 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $119 | $119 | $119 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $133 | $133 | $133 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $182 | $182 | $182 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $149 | $149 | $149 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $187 | $187 | $187 |
| Initial treatment first degree burn CPT 16000 • Emergency | $56 | $56 | $56 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $19 | $19 | $19 |
| Emergency department visit low severity CPT 99282 • Emergency | $31 | $31 | $31 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $69 | $69 | $69 |
| Emergency department visit high severity CPT 99284 • Emergency | $108 | $108 | $108 |
| Emergency department visit highest severity CPT 99285 • Emergency | $169 | $169 | $169 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $231 | $231 | $231 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $126 | $126 | $126 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $164 | $164 | $164 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $346 | $346 | $346 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $195 | $195 | $195 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $228 | $228 | $228 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $197 | $197 | $197 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $248 | $248 | $248 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $368 | $368 | $368 |