| Tonsillectomy primary under age 12 CPT 42826 • ENT | $163 | $163 | $163 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $34 | $34 | $34 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $34 | $34 | $34 |
| Tympanostomy tube insertion CPT 69436 • ENT | $114 | $114 | $114 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $567 | $567 | $567 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $191 | $191 | $191 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $47 | $47 | $47 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $34 | $34 | $34 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $100 | $100 | $100 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $23 | $23 | $23 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $90 | $90 | $90 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $90 | $90 | $90 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $24 | $24 | $24 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $206 | $206 | $206 |
| Initial treatment first degree burn CPT 16000 • Emergency | $5 | $5 | $5 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $18 | $18 | $18 |
| Emergency department visit low severity CPT 99282 • Emergency | $26 | $26 | $26 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $40 | $40 | $40 |
| Emergency department visit high severity CPT 99284 • Emergency | $50 | $50 | $50 |
| Emergency department visit highest severity CPT 99285 • Emergency | $126 | $126 | $126 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $227 | $227 | $227 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $34 | $34 | $34 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $19 | $19 | $19 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $288 | $288 | $288 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $24 | $24 | $24 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $142 | $142 | $142 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $83 | $83 | $83 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $31 | $31 | $31 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $29 | $29 | $29 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $216 | $216 | $216 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $33 | $33 | $33 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $41 | $41 | $41 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $49 | $49 | $49 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $238 | $238 | $238 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $49 | $49 | $49 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $76 | $76 | $76 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $57 | $57 | $57 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $68 | $68 | $68 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $34 | $34 | $34 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $67 | $67 | $67 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $510 | $510 | $510 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $38 | $38 | $38 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $239 | $239 | $239 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $71 | $71 | $71 |
| Esophageal motility study CPT 91010 • Gastroenterology | $32 | $32 | $32 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $269 | $269 | $269 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $94 | $94 | $94 |
| Auto-added CPT 00102 • General | $34 | $34 | $34 |
| Auto-added CPT 00104 • General | $34 | $34 | $34 |