| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $27 | $27 | $27 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $9 | $9 | $9 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $30 | $30 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $439 | $439 | $439 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,037 | $1,037 | $1,037 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $6 | $6 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $71 | $71 | $71 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $89 | $89 | $89 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $18 | $18 | $18 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $83 | $83 | $83 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $25 | $25 | $25 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $33 | $33 | $33 |
| Initial treatment first degree burn CPT 16000 • Emergency | $37 | $37 | $37 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $11 | $11 | $11 |
| Emergency department visit low severity CPT 99282 • Emergency | $42 | $42 | $42 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $78 | $78 | $78 |
| Emergency department visit high severity CPT 99284 • Emergency | $120 | $120 | $120 |
| Emergency department visit highest severity CPT 99285 • Emergency | $191 | $191 | $191 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $27 | $27 | $27 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $53 | $53 | $53 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $75 | $75 | $75 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $222 | $222 | $222 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $38 | $38 | $38 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $38 | $38 | $38 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $15 | $15 | $15 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $57 | $57 | $57 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $23 | $23 | $23 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $30 | $30 | $30 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $30 | $30 | $30 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $349 | $349 | $349 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $178 | $178 | $178 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $63 | $63 | $63 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $30 | $30 | $30 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $41 | $41 | $41 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $147 | $147 | $147 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $196 | $196 | $196 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $223 | $223 | $223 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $37 | $37 | $37 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $206 | $206 | $206 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $25 | $25 | $25 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $162 | $162 | $162 |
| Esophageal motility study CPT 91010 • Gastroenterology | $30 | $30 | $30 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $349 | $349 | $349 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $205 | $205 | $205 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |