| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $104 | $104 | $104 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $97 | $97 | $97 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $14 | $14 | $14 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $321 | $321 | $321 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $140 | $140 | $140 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $109 | $109 | $109 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $53 | $53 | $53 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $95 | $95 | $95 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $603 | $603 | $603 |
| Septoplasty CPT 30520 • ENT | $781 | $781 | $781 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $188 | $188 | $188 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $276 | $276 | $276 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $316 | $316 | $316 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $487 | $487 | $487 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $722 | $722 | $722 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $351 | $351 | $351 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $569 | $569 | $569 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $912 | $912 | $912 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $210 | $210 | $210 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $460 | $460 | $460 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $498 | $498 | $498 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $408 | $408 | $408 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $326 | $326 | $326 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $55 | $55 | $55 |
| Tympanostomy tube insertion CPT 69436 • ENT | $270 | $270 | $270 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,333 | $1,333 | $1,333 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,595 | $1,595 | $1,595 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $67 | $67 | $67 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $135 | $135 | $135 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $274 | $274 | $274 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $161 | $161 | $161 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $180 | $180 | $180 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $166 | $166 | $166 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $281 | $281 | $281 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $253 | $253 | $253 |
| Initial treatment first degree burn CPT 16000 • Emergency | $112 | $112 | $112 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $24 | $24 | $24 |
| Emergency department visit low severity CPT 99282 • Emergency | $40 | $40 | $40 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $90 | $90 | $90 |
| Emergency department visit high severity CPT 99284 • Emergency | $141 | $141 | $141 |
| Emergency department visit highest severity CPT 99285 • Emergency | $220 | $220 | $220 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $301 | $301 | $301 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $151 | $151 | $151 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $222 | $222 | $222 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $469 | $469 | $469 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $265 | $265 | $265 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $310 | $310 | $310 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $268 | $268 | $268 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $337 | $337 | $337 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $500 | $500 | $500 |