| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $100 | $100 | $100 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $75 | $75 | $75 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $6 | $6 | $6 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $148 | $148 | $148 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $102 | $102 | $102 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $81 | $81 | $81 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $47 | $47 | $47 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $144 | $144 | $144 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $433 | $433 | $433 |
| Septoplasty CPT 30520 • ENT | $605 | $605 | $605 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $134 | $134 | $134 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $86 | $86 | $86 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $210 | $210 | $210 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $323 | $323 | $323 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $479 | $479 | $479 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $234 | $234 | $234 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $378 | $378 | $378 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $604 | $604 | $604 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $191 | $191 | $191 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $323 | $323 | $323 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $339 | $339 | $339 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $279 | $279 | $279 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $225 | $225 | $225 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $37 | $37 | $37 |
| Tympanostomy tube insertion CPT 69436 • ENT | $184 | $184 | $184 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $930 | $930 | $930 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,107 | $1,107 | $1,107 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $47 | $47 | $47 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $97 | $97 | $97 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $177 | $177 | $177 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $162 | $162 | $162 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $172 | $172 | $172 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $115 | $115 | $115 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $149 | $149 | $149 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $181 | $181 | $181 |
| Initial treatment first degree burn CPT 16000 • Emergency | $77 | $77 | $77 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $19 | $19 | $19 |
| Emergency department visit low severity CPT 99282 • Emergency | $36 | $36 | $36 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $58 | $58 | $58 |
| Emergency department visit high severity CPT 99284 • Emergency | $107 | $107 | $107 |
| Emergency department visit highest severity CPT 99285 • Emergency | $160 | $160 | $160 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $246 | $246 | $246 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $110 | $110 | $110 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $163 | $163 | $163 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $156 | $156 | $156 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $185 | $185 | $185 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $217 | $217 | $217 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $188 | $188 | $188 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $236 | $236 | $236 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $340 | $340 | $340 |