| Tonsillectomy primary under age 12 CPT 42826 • ENT | $235 | $235 | $235 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $96 | $96 | $96 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $21 | $21 | $21 |
| Tympanostomy tube insertion CPT 69436 • ENT | $21 | $21 | $21 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $392 | $392 | $392 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $45 | $45 | $45 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $6 | $6 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $70 | $70 | $70 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $132 | $132 | $132 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $4 | $4 | $4 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $26 | $26 | $26 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $10 | $10 | $10 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $94 | $94 | $94 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $15 | $15 | $15 |
| Initial treatment first degree burn CPT 16000 • Emergency | $20 | $20 | $20 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $50 | $50 | $50 |
| Emergency department visit low severity CPT 99282 • Emergency | $18 | $18 | $18 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $5 | $5 | $5 |
| Emergency department visit high severity CPT 99284 • Emergency | $109 | $109 | $109 |
| Emergency department visit highest severity CPT 99285 • Emergency | $121 | $121 | $121 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $29 | $29 | $29 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $10 | $10 | $10 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $15 | $15 | $15 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $118 | $118 | $118 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $62 | $62 | $62 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $48 | $48 | $48 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $22 | $22 | $22 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $19 | $19 | $19 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $223 | $223 | $223 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $162 | $162 | $162 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $45 | $45 | $45 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $51 | $51 | $51 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $348 | $348 | $348 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $89 | $89 | $89 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $15 | $15 | $15 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $257 | $257 | $257 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $36 | $36 | $36 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $192 | $192 | $192 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $110 | $110 | $110 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $194 | $194 | $194 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $79 | $79 | $79 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $2,134 | $2,134 | $2,134 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $239 | $239 | $239 |
| Esophageal motility study CPT 91010 • Gastroenterology | $85 | $85 | $85 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $379 | $379 | $379 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $265 | $265 | $265 |
| Auto-added CPT 00102 • General | $45 | $45 | $45 |
| Auto-added CPT 00104 • General | $45 | $45 | $45 |