| Destruction premalignant lesion first lesion CPT 17000 • Dermatology | $57 | $403 | $750 |
| Destruction premalignant lesion 2-14 each additional CPT 17003 • Dermatology | $57 | $403 | $750 |
| Destruction premalignant lesion 15 or more CPT 17004 • Dermatology | $57 | $316 | $750 |
| Destruction benign lesions up to 14 CPT 17110 • Dermatology | $57 | $403 | $750 |
| Destruction benign lesions 15 or more CPT 17111 • Dermatology | $57 | $403 | $750 |
| Photochemotherapy tar and UV-B CPT 96910 • Dermatology | $196 | $196 | $196 |
| Laser treatment dermatologic up to 250 sq cm CPT 96920 • Dermatology | $750 | $750 | $750 |
| Submucous resection inferior turbinate CPT 30140 • ENT | $655 | $10,309 | $28,516 |
| Septoplasty CPT 30520 • ENT | $750 | $17,283 | $33,816 |
| Ablation inferior turbinate unilateral intramural CPT 30801 • ENT | $750 | $7,087 | $19,682 |
| Nasal endoscopy diagnostic CPT 31231 • ENT | $57 | $356 | $655 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $655 | $10,056 | $28,516 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $750 | $16,596 | $45,983 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $750 | $15,523 | $42,765 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $750 | $16,253 | $45,983 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $750 | $16,596 | $45,983 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $750 | $23,367 | $45,983 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $156 | $6,863 | $19,682 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $750 | $16,802 | $45,983 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $750 | $15,090 | $42,765 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $750 | $17,283 | $33,816 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $750 | $12,107 | $33,816 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $57 | $403 | $750 |
| Tympanostomy tube insertion CPT 69436 • ENT | $750 | $15,854 | $45,983 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $750 | $15,729 | $42,765 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $750 | $15,729 | $42,765 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $64 | $64 | $64 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $57 | $303 | $750 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $57 | $319 | $750 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $57 | $403 | $750 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $57 | $403 | $750 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $57 | $403 | $750 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $57 | $345 | $750 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $57 | $348 | $750 |
| Initial treatment first degree burn CPT 16000 • Emergency | $57 | $91 | $126 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $15 | $15 | $15 |
| Emergency department visit low severity CPT 99282 • Emergency | $55 | $55 | $55 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $94 | $94 | $94 |
| Emergency department visit high severity CPT 99284 • Emergency | $159 | $159 | $159 |
| Emergency department visit highest severity CPT 99285 • Emergency | $231 | $231 | $231 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $356 | $356 | $356 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $156 | $156 | $156 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $57 | $631 | $1,088 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $634 | $7,022 | $19,682 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $634 | $9,935 | $28,516 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $655 | $14,586 | $28,516 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $655 | $10,086 | $28,516 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $655 | $10,086 | $28,516 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $750 | $16,577 | $45,983 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $750 | $15,940 | $45,983 |