| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $12 | $12 | $12 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $187 | $187 | $187 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $136 | $136 | $136 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $162 | $162 | $162 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $86 | $86 | $86 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $193 | $193 | $193 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $562 | $562 | $562 |
| Septoplasty CPT 30520 • ENT | $803 | $803 | $803 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $289 | $289 | $289 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $264 | $264 | $264 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $211 | $211 | $211 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $357 | $357 | $357 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $523 | $523 | $523 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $258 | $258 | $258 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $415 | $415 | $415 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $661 | $661 | $661 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $247 | $247 | $247 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $381 | $381 | $381 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $396 | $396 | $396 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $330 | $330 | $330 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $272 | $272 | $272 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $63 | $63 | $63 |
| Tympanostomy tube insertion CPT 69436 • ENT | $208 | $208 | $208 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $1,148 | $1,148 | $1,148 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,355 | $1,355 | $1,355 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $49 | $49 | $49 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $147 | $147 | $147 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $261 | $261 | $261 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $113 | $113 | $113 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $137 | $137 | $137 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $138 | $138 | $138 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $295 | $295 | $295 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $323 | $323 | $323 |
| Initial treatment first degree burn CPT 16000 • Emergency | $88 | $88 | $88 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $27 | $27 | $27 |
| Emergency department visit low severity CPT 99282 • Emergency | $54 | $54 | $54 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $80 | $80 | $80 |
| Emergency department visit high severity CPT 99284 • Emergency | $152 | $152 | $152 |
| Emergency department visit highest severity CPT 99285 • Emergency | $224 | $224 | $224 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $351 | $351 | $351 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $158 | $158 | $158 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $166 | $166 | $166 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $396 | $396 | $396 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $505 | $505 | $505 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $517 | $517 | $517 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $1,321 | $1,321 | $1,321 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $639 | $639 | $639 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $314 | $314 | $314 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $315 | $315 | $315 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $447 | $447 | $447 |