| POS | CPT | Description | MCR Allowed | Coins 20% | Comment |
| Office | 83014 | HPYLORI DRUG ADMN | $11.26 | $2.25 | |
| Office | 91110 | GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R | $643.25 | $128.65 | |
| Office | 99202 | OFFICE VISIT NEW LEVEL 2 | $52.08 | $10.42 | |
| Office | 99203 | OFFICE VISIT NEW LEVEL 3 | $75.84 | $15.17 | |
| Office | 99204 | OFFICE VISIT NEW LEVEL 4 | $117.87 | $23.57 | |
| Office | 99211 | OFFICE VISIT EST. LEVEL 1 | $14.53 | $2.91 | |
| Office | 99212 | OFFICE VISIT EST. LEVEL 2 | $29.92 | $5.98 | |
| Office | 99213 | OFFICE VISIT EST. LEVEL 3 | $50.57 | $10.11 | |
| Office | 99214 | OFFICE VISIT EST. LEVEL 4 | $76.01 | $15.20 | |
| Office | 99242 | OFFICE CONSULTATION LEVEL 2 | $0.00 | Invalid CPT for the year 2010 | |
| Office | 99243 | OFFICE CONSULTATION LEVEL 3 | $0.00 | Invalid CPT for the year 2010 | |
| Office | 99244 | OFFICE CONSULTATION LEVEL 4 | $0.00 | Invalid CPT for the year 2010 |
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