| Tonsillectomy primary under age 12 CPT 42826 • ENT | $208 | $208 | $208 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $35 | $35 | $35 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $32 | $32 | $32 |
| Tympanostomy tube insertion CPT 69436 • ENT | $21 | $21 | $21 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $162 | $487 | $811 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $44 | $44 | $44 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $38 | $38 | $38 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $10 | $10 | $10 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $146 | $146 | $146 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $8 | $8 | $8 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $44 | $44 | $44 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $9 | $9 | $9 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $49 | $148 | $247 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $113 | $113 | $113 |
| Initial treatment first degree burn CPT 16000 • Emergency | $14 | $29 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $69 | $69 | $69 |
| Emergency department visit low severity CPT 99282 • Emergency | $33 | $46 | $59 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $90 | $90 | $90 |
| Emergency department visit high severity CPT 99284 • Emergency | $10 | $52 | $95 |
| Emergency department visit highest severity CPT 99285 • Emergency | $21 | $21 | $21 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $23 | $23 | $23 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $43 | $43 | $43 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $82 | $82 | $82 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $44 | $44 | $44 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $29 | $29 | $29 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $28 | $36 | $44 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $122 | $122 | $122 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $21 | $21 | $21 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $37 | $141 | $246 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $44 | $44 | $44 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $256 | $298 | $341 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $44 | $44 | $44 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $39 | $212 | $385 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $73 | $73 | $73 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $44 | $157 | $270 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $72 | $72 | $72 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $43 | $43 | $43 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $193 | $290 | $386 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $376 | $376 | $376 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $159 | $159 | $159 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $240 | $240 | $240 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $135 | $202 | $269 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $72 | $72 | $72 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $2,993 | $2,993 | $2,993 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $176 | $176 | $176 |
| Esophageal motility study CPT 91010 • Gastroenterology | $118 | $118 | $118 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $505 | $505 | $505 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $55 | $224 | $393 |
| Auto-added CPT 00102 • General | $44 | $44 | $44 |
| Auto-added CPT 00104 • General | $44 | $44 | $44 |