| Excision malignant lesion face 0.5cm or less CPT 11640 • Dermatology | $92 | $92 | $92 |
| Avulsion of nail plate partial or complete CPT 11730 • Dermatology | $52 | $52 | $52 |
| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $74 | $74 | $74 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $7 | $7 | $7 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $121 | $121 | $121 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $82 | $82 | $82 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $96 | $96 | $96 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $86 | $86 | $86 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $45 | $45 | $45 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $128 | $128 | $128 |
| Septoplasty CPT 30520 • ENT | $737 | $737 | $737 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $166 | $166 | $166 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $85 | $85 | $85 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $279 | $279 | $279 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $473 | $473 | $473 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $231 | $231 | $231 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $129 | $129 | $129 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $120 | $120 | $120 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $271 | $271 | $271 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $149 | $149 | $149 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $319 | $319 | $319 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $140 | $140 | $140 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $118 | $118 | $118 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $234 | $234 | $234 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $35 | $35 | $35 |
| Tympanostomy tube insertion CPT 69436 • ENT | $116 | $116 | $116 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $407 | $407 | $407 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $481 | $481 | $481 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $23 | $23 | $23 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $116 | $116 | $116 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $98 | $98 | $98 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $43 | $43 | $43 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $42 | $42 | $42 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $122 | $122 | $122 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $190 | $190 | $190 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $308 | $308 | $308 |
| Initial treatment first degree burn CPT 16000 • Emergency | $49 | $49 | $49 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $8 | $8 | $8 |
| Emergency department visit low severity CPT 99282 • Emergency | $30 | $30 | $30 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $51 | $51 | $51 |
| Emergency department visit high severity CPT 99284 • Emergency | $86 | $86 | $86 |
| Emergency department visit highest severity CPT 99285 • Emergency | $125 | $125 | $125 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $152 | $152 | $152 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $76 | $76 | $76 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $168 | $168 | $168 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $131 | $131 | $131 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $271 | $271 | $271 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $79 | $79 | $79 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $770 | $770 | $770 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $533 | $533 | $533 |