| Foot insert removable molded HCPCS L3000 • Durable Medical Equipment | $249 | $249 | $249 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $366 | $366 | $366 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $238 | $238 | $238 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $316 | $316 | $316 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $380 | $380 | $380 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $51 | $51 | $51 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $312 | $312 | $312 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $443 | $443 | $443 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $51 | $51 | $51 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $345 | $345 | $345 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $362 | $362 | $362 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $254 | $254 | $254 |
| Tympanostomy tube insertion CPT 69436 • ENT | $209 | $209 | $209 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $992 | $992 | $992 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $51 | $51 | $51 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $130 | $130 | $130 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $219 | $219 | $219 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $99 | $99 | $99 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $51 | $51 | $51 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $385 | $385 | $385 |
| Initial treatment first degree burn CPT 16000 • Emergency | $81 | $81 | $81 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $11 | $11 | $11 |
| Emergency department visit low severity CPT 99282 • Emergency | $27 | $27 | $27 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $67 | $67 | $67 |
| Emergency department visit high severity CPT 99284 • Emergency | $152 | $152 | $152 |
| Emergency department visit highest severity CPT 99285 • Emergency | $164 | $164 | $164 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $264 | $264 | $264 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $135 | $135 | $135 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $181 | $181 | $181 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $51 | $51 | $51 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $463 | $463 | $463 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $51 | $51 | $51 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $314 | $314 | $314 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $306 | $306 | $306 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $437 | $437 | $437 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $403 | $403 | $403 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $411 | $411 | $411 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $522 | $522 | $522 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $504 | $504 | $504 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $230 | $230 | $230 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $539 | $539 | $539 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $546 | $546 | $546 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $3,089 | $3,089 | $3,089 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $376 | $376 | $376 |
| Esophageal motility study CPT 91010 • Gastroenterology | $223 | $223 | $223 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $472 | $472 | $472 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |
| Auto-added CPT 00124 • General | $30 | $30 | $30 |
| Auto-added CPT 00160 • General | $30 | $30 | $30 |