| Nasal endoscopy diagnostic CPT 31231 • ENT | $30 | $30 | $30 |
| Nasal endoscopy with biopsy CPT 31237 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with ethmoidectomy total CPT 31255 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with maxillary antrostomy CPT 31256 • ENT | $175 | $175 | $175 |
| Nasal/sinus endoscopy with frontal sinus exploration CPT 31267 • ENT | $30 | $30 | $30 |
| Nasal/sinus endoscopy with sphenoidotomy CPT 31276 • ENT | $30 | $30 | $30 |
| Incision and drainage peritonsillar abscess CPT 42700 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy under age 12 CPT 42820 • ENT | $30 | $30 | $30 |
| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $30 | $30 | $30 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $30 | $30 | $30 |
| Tympanostomy tube insertion CPT 69436 • ENT | $30 | $30 | $30 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $1,037 | $1,037 | $1,037 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $30 | $30 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $30 | $30 | $30 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $30 | $30 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $258 | $258 | $258 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $30 | $30 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $30 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $76 | $76 | $76 |
| Emergency department visit low severity CPT 99282 • Emergency | $76 | $76 | $76 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $78 | $78 | $78 |
| Emergency department visit high severity CPT 99284 • Emergency | $153 | $153 | $153 |
| Emergency department visit highest severity CPT 99285 • Emergency | $191 | $191 | $191 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $30 | $30 | $30 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $30 | $30 | $30 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $151 | $151 | $151 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $296 | $296 | $296 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $384 | $384 | $384 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $228 | $228 | $228 |
| 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 | $30 | $30 | $30 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $30 | $30 | $30 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $452 | $452 | $452 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $30 | $30 | $30 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $53 | $53 | $53 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $324 | $324 | $324 |
| Esophageal motility study CPT 91010 • Gastroenterology | $30 | $30 | $30 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $465 | $465 | $465 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |
| Auto-added CPT 00124 • General | $30 | $30 | $30 |
| Auto-added CPT 00160 • General | $30 | $30 | $30 |
| Auto-added CPT 00170 • General | $30 | $30 | $30 |
| Auto-added CPT 00190 • General | $30 | $30 | $30 |