| Tonsillectomy primary under age 12 CPT 42826 • ENT | $125 | $125 | $125 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $145 | $145 | $145 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $3 | $3 | $3 |
| Tympanostomy tube insertion CPT 69436 • ENT | $23 | $23 | $23 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $30 | $30 | $30 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $726 | $726 | $726 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $7 | $7 | $7 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $73 | $73 | $73 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $146 | $146 | $146 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $9 | $9 | $9 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $58 | $58 | $58 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $27 | $27 | $27 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $21 | $21 | $21 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $278 | $278 | $278 |
| Initial treatment first degree burn CPT 16000 • Emergency | $9 | $9 | $9 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $26 | $39 | $52 |
| Emergency department visit low severity CPT 99282 • Emergency | $50 | $54 | $59 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $58 | $67 | $75 |
| Emergency department visit high severity CPT 99284 • Emergency | $49 | $95 | $142 |
| Emergency department visit highest severity CPT 99285 • Emergency | $87 | $148 | $209 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $34 | $34 | $34 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $9 | $9 | $9 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $22 | $22 | $22 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $306 | $306 | $306 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $59 | $59 | $59 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $128 | $128 | $128 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $112 | $112 | $112 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $75 | $75 | $75 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $228 | $228 | $228 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $110 | $110 | $110 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $30 | $30 | $30 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $262 | $262 | $262 |
| 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 | $76 | $76 | $76 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $168 | $168 | $168 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $54 | $54 | $54 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $34 | $34 | $34 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $223 | $223 | $223 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $222 | $222 | $222 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $22 | $22 | $22 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $453 | $453 | $453 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $92 | $92 | $92 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $250 | $250 | $250 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $320 | $320 | $320 |
| Esophageal motility study CPT 91010 • Gastroenterology | $220 | $220 | $220 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $315 | $315 | $315 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $356 | $356 | $356 |
| Auto-added CPT 00102 • General | $50 | $50 | $50 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |