| Tonsillectomy primary under age 12 CPT 42826 • ENT | $44 | $44 | $44 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $44 | $44 | $44 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $6 | $24 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $44 | $44 | $44 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $44 | $83 | $122 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $44 | $44 | $44 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $19 | $19 | $19 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $57 | $115 | $172 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $82 | $82 | $82 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $29 | $29 | $29 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $10 | $10 | $10 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $7 | $7 | $7 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $27 | $27 | $27 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $75 | $75 | $75 |
| Initial treatment first degree burn CPT 16000 • Emergency | $7 | $25 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $9 | $9 | $9 |
| Emergency department visit low severity CPT 99282 • Emergency | $3 | $3 | $3 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $28 | $113 | $197 |
| Emergency department visit high severity CPT 99284 • Emergency | $154 | $207 | $285 |
| Emergency department visit highest severity CPT 99285 • Emergency | $218 | $353 | $487 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $86 | $310 | $533 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $13 | $13 | $13 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $33 | $33 | $33 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $13 | $13 | $13 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $88 | $97 | $107 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $44 | $116 | $187 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $131 | $189 | $246 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $104 | $104 | $104 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $37 | $141 | $246 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $48 | $48 | $48 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $44 | $44 | $44 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $76 | $76 | $76 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $289 | $337 | $385 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $489 | $489 | $489 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $25 | $94 | $164 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $181 | $329 | $477 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $108 | $108 | $108 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $58 | $171 | $284 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $38 | $250 | $501 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $106 | $159 | $212 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $48 | $48 | $48 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $386 | $430 | $517 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $112 | $112 | $112 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $285 | $442 | $599 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $70 | $70 | $70 |
| Esophageal motility study CPT 91010 • Gastroenterology | $64 | $64 | $64 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $379 | $402 | $425 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $394 | $421 | $448 |
| Auto-added CPT 00102 • General | $44 | $44 | $44 |
| Auto-added CPT 00104 • General | $44 | $44 | $44 |