| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $83 | $109 | $154 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $52 | $94 | $116 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $4 | $8 | $15 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $161 | $207 | $230 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $63 | $133 | $167 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $79 | $159 | $199 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $60 | $82 | $92 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $66 | $160 | $207 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $30 | $451 | $690 |
| Septoplasty CPT 30520 • ENT | $568 | $847 | $986 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $200 | $257 | $355 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $171 | $273 | $324 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $300 | $370 | $406 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $270 | $382 | $439 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $397 | $561 | $643 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $30 | $143 | $317 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $314 | $444 | $510 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $501 | $708 | $812 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $181 | $303 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $281 | $405 | $468 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $292 | $421 | $486 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $242 | $351 | $405 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $198 | $289 | $334 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $47 | $59 | $78 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $174 | $256 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $826 | $1,215 | $1,410 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $978 | $1,436 | $1,665 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $41 | $48 | $52 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $87 | $149 | $180 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $172 | $271 | $320 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $99 | $126 | $139 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $95 | $125 | $169 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $146 | $162 | $169 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $30 | $243 | $363 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $248 | $396 |
| Initial treatment first degree burn CPT 16000 • Emergency | $64 | $82 | $108 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $21 | $27 | $30 |
| Emergency department visit low severity CPT 99282 • Emergency | $41 | $54 | $60 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $63 | $80 | $89 |
| Emergency department visit high severity CPT 99284 • Emergency | $118 | $153 | $170 |
| Emergency department visit highest severity CPT 99285 • Emergency | $174 | $225 | $250 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $261 | $348 | $391 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $118 | $157 | $176 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $131 | $179 | $203 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $143 | $372 | $486 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $322 | $521 | $620 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $198 | $378 | $635 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $173 | $1,139 | $1,623 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $216 | $595 | $785 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $313 | $361 | $385 |