| Nasal endoscopy diagnostic CPT 31231 • ENT | $50 | $288 | $525 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $498 | $512 | $525 |
| Nasal/sinus endoscopy with ethmoidectomy partial CPT 31254 • ENT | $495 | $569 | $643 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $495 | $508 | $520 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $495 | $508 | $520 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $495 | $508 | $520 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $495 | $508 | $520 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $323 | $422 | $520 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $495 | $508 | $520 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $495 | $508 | $520 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $495 | $569 | $643 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $495 | $569 | $643 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $50 | $285 | $520 |
| Tympanostomy tube insertion CPT 69436 • ENT | $495 | $508 | $520 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $495 | $508 | $520 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $495 | $508 | $520 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $50 | $285 | $520 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $323 | $422 | $520 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $50 | $285 | $520 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $50 | $285 | $520 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $50 | $285 | $520 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $50 | $285 | $520 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $50 | $285 | $520 |
| Initial treatment first degree burn CPT 16000 • Emergency | $50 | $50 | $50 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $495 | $508 | $520 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $323 | $422 | $520 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $498 | $512 | $525 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $498 | $512 | $525 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $498 | $799 | $1,101 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $498 | $512 | $525 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $495 | $508 | $520 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $495 | $508 | $520 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $498 | $512 | $525 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $498 | $512 | $525 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $498 | $512 | $525 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $495 | $508 | $520 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $323 | $422 | $520 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $323 | $422 | $520 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $498 | $512 | $525 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $498 | $512 | $525 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $498 | $512 | $525 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $498 | $512 | $525 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $498 | $512 | $525 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $498 | $512 | $525 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $323 | $424 | $525 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $323 | $424 | $525 |
| Esophageal motility study CPT 91010 • Gastroenterology | $520 | $520 | $520 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $520 | $520 | $520 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $520 | $520 | $520 |
| Auto-added CPT 00102 • General | $490 | $490 | $490 |