| Tonsillectomy primary under age 12 CPT 42826 • ENT | $21 | $21 | $21 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $83 | $83 | $83 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $4 | $22 | $39 |
| Tympanostomy tube insertion CPT 69436 • ENT | $20 | $20 | $20 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $105 | $105 | $105 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $619 | $619 | $619 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $6 | $6 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $55 | $55 | $55 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $73 | $73 | $73 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $40 | $52 | $65 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $95 | $110 | $126 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $13 | $13 | $13 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $37 | $37 | $37 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $103 | $103 | $103 |
| Initial treatment first degree burn CPT 16000 • Emergency | $27 | $34 | $40 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $2 | $2 | $2 |
| Emergency department visit low severity CPT 99282 • Emergency | $50 | $50 | $50 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $53 | $53 | $53 |
| Emergency department visit high severity CPT 99284 • Emergency | $98 | $102 | $107 |
| Emergency department visit highest severity CPT 99285 • Emergency | $118 | $118 | $118 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $108 | $108 | $108 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $40 | $69 | $98 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $17 | $17 | $17 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $23 | $23 | $23 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $41 | $41 | $41 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $86 | $129 | $171 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $74 | $74 | $74 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $19 | $19 | $19 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $40 | $155 | $269 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $195 | $195 | $195 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $40 | $42 | $45 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $73 | $73 | $73 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $439 | $439 | $440 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $217 | $217 | $217 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $40 | $40 | $41 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $157 | $234 | $310 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $10 | $10 | $10 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $37 | $44 | $52 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $221 | $297 | $374 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $73 | $217 | $362 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $372 | $372 | $372 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $40 | $46 | $53 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $236 | $354 | $472 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $47 | $47 | $47 |
| Esophageal motility study CPT 91010 • Gastroenterology | $29 | $29 | $29 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $36 | $36 | $36 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $55 | $55 | $55 |
| Auto-added CPT 00102 • General | $40 | $40 | $40 |
| Auto-added CPT 00104 • General | $40 | $40 | $40 |