| Tonsillectomy primary under age 12 CPT 42826 • ENT | $119 | $119 | $119 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $148 | $148 | $148 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $42 | $42 | $42 |
| Tympanostomy tube insertion CPT 69436 • ENT | $71 | $71 | $71 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $397 | $397 | $397 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $141 | $141 | $141 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $17 | $17 | $17 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $54 | $54 | $54 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $13 | $13 | $13 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $10 | $10 | $10 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $13 | $13 | $13 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $135 | $135 | $135 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $19 | $19 | $19 |
| Initial treatment first degree burn CPT 16000 • Emergency | $58 | $58 | $58 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $7 | $7 | $7 |
| Emergency department visit low severity CPT 99282 • Emergency | $22 | $22 | $22 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $51 | $51 | $51 |
| Emergency department visit high severity CPT 99284 • Emergency | $64 | $64 | $64 |
| Emergency department visit highest severity CPT 99285 • Emergency | $93 | $93 | $93 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $29 | $29 | $29 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $84 | $84 | $84 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $143 | $143 | $143 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $133 | $133 | $133 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $52 | $52 | $52 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $35 | $35 | $35 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $996 | $996 | $996 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $457 | $457 | $457 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $32 | $32 | $32 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $102 | $102 | $102 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $146 | $146 | $146 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $65 | $65 | $65 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $331 | $331 | $331 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $42 | $42 | $42 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $21 | $21 | $21 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $380 | $380 | $380 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $51 | $51 | $51 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $25 | $25 | $25 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $183 | $183 | $183 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $306 | $306 | $306 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $450 | $450 | $450 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $84 | $84 | $84 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $96 | $96 | $96 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $123 | $123 | $123 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $45 | $45 | $45 |
| Esophageal motility study CPT 91010 • Gastroenterology | $229 | $229 | $229 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $84 | $84 | $84 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $84 | $84 | $84 |
| Auto-added CPT 00102 • General | $42 | $42 | $42 |
| Auto-added CPT 00104 • General | $42 | $42 | $42 |