| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $251 | $251 | $251 |
| Nebulizer compressor HCPCS E0570 • Durable Medical Equipment | $77 | $77 | $77 |
| Cervical collar nonadjustable HCPCS L0180 • Durable Medical Equipment | $369 | $369 | $369 |
| Lumbar support corset HCPCS L0650 • Durable Medical Equipment | $1,015 | $1,015 | $1,015 |
| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $533 | $533 | $533 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $461 | $461 | $461 |
| Septoplasty CPT 30520 • ENT | $1,047 | $1,047 | $1,047 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $521 | $521 | $521 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $303 | $303 | $303 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $398 | $398 | $398 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $432 | $432 | $432 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $879 | $879 | $879 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $489 | $489 | $489 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $413 | $413 | $413 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $1,027 | $1,027 | $1,027 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $475 | $475 | $475 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $451 | $451 | $451 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $471 | $471 | $471 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $393 | $393 | $393 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $325 | $325 | $325 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $74 | $74 | $74 |
| Tympanostomy tube insertion CPT 69436 • ENT | $245 | $245 | $245 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,577 | $1,577 | $1,577 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,858 | $1,858 | $1,858 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $60 | $60 | $60 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $192 | $192 | $192 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $330 | $330 | $330 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $145 | $145 | $145 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $176 | $176 | $176 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $176 | $176 | $176 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $410 | $410 | $410 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $441 | $441 | $441 |
| Initial treatment first degree burn CPT 16000 • Emergency | $129 | $129 | $129 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $40 | $40 | $40 |
| Emergency department visit low severity CPT 99282 • Emergency | $77 | $77 | $77 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $114 | $114 | $114 |
| Emergency department visit high severity CPT 99284 • Emergency | $193 | $193 | $193 |
| Emergency department visit highest severity CPT 99285 • Emergency | $282 | $282 | $282 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $436 | $436 | $436 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $220 | $220 | $220 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $420 | $420 | $420 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $470 | $470 | $470 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $603 | $603 | $603 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $1,066 | $1,066 | $1,066 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $1,794 | $1,794 | $1,794 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $499 | $499 | $499 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $496 | $496 | $496 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $617 | $617 | $617 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $882 | $882 | $882 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $977 | $977 | $977 |