| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $99 | $99 | $99 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $69 | $69 | $69 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $12 | $12 | $12 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $198 | $198 | $198 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $99 | $99 | $99 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $114 | $114 | $114 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $39 | $39 | $39 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $146 | $146 | $146 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $426 | $426 | $426 |
| Septoplasty CPT 30520 • ENT | $553 | $553 | $553 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $226 | $226 | $226 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $90 | $90 | $90 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $223 | $223 | $223 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $344 | $344 | $344 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $510 | $510 | $510 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $248 | $248 | $248 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $402 | $402 | $402 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $644 | $644 | $644 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $189 | $189 | $189 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $325 | $325 | $325 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $352 | $352 | $352 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $289 | $289 | $289 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $230 | $230 | $230 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $39 | $39 | $39 |
| Tympanostomy tube insertion CPT 69436 • ENT | $191 | $191 | $191 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $942 | $942 | $942 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,127 | $1,127 | $1,127 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $49 | $49 | $49 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $96 | $96 | $96 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $180 | $180 | $180 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $114 | $114 | $114 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $128 | $128 | $128 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $118 | $118 | $118 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $199 | $199 | $199 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $256 | $256 | $256 |
| Initial treatment first degree burn CPT 16000 • Emergency | $79 | $79 | $79 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $18 | $18 | $18 |
| Emergency department visit low severity CPT 99282 • Emergency | $29 | $29 | $29 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $66 | $66 | $66 |
| Emergency department visit high severity CPT 99284 • Emergency | $103 | $103 | $103 |
| Emergency department visit highest severity CPT 99285 • Emergency | $161 | $161 | $161 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $221 | $221 | $221 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $111 | $111 | $111 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $157 | $157 | $157 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $332 | $332 | $332 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $377 | $377 | $377 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $219 | $219 | $219 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $189 | $189 | $189 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $239 | $239 | $239 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $353 | $353 | $353 |