| Tonsillectomy primary under age 12 CPT 42826 • ENT | $29 | $161 | $292 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $241 | $241 | $241 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $7 | $25 | $44 |
| Tympanostomy tube insertion CPT 69436 • ENT | $23 | $86 | $149 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $42 | $227 | $413 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $732 | $853 | $975 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $9 | $21 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $17 | $58 | $99 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $19 | $31 | $42 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $39 | $58 | $76 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $14 | $28 | $42 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $61 | $77 | $93 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $12 | $27 | $42 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $149 | $185 | $221 |
| Initial treatment first degree burn CPT 16000 • Emergency | $6 | $6 | $6 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $3 | $33 | $63 |
| Emergency department visit low severity CPT 99282 • Emergency | $29 | $32 | $34 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $27 | $52 | $77 |
| Emergency department visit high severity CPT 99284 • Emergency | $44 | $64 | $84 |
| Emergency department visit highest severity CPT 99285 • Emergency | $22 | $115 | $207 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $34 | $120 | $207 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $13 | $27 | $42 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $18 | $98 | $178 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $22 | $189 | $355 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $122 | $287 | $453 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $475 | $475 | $475 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $123 | $676 | $1,229 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $568 | $568 | $569 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $278 | $278 | $278 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $269 | $269 | $269 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $42 | $50 | $57 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $211 | $317 | $422 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $488 | $488 | $488 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $477 | $477 | $477 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $38 | $40 | $42 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $42 | $86 | $131 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $6 | $6 | $6 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $31 | $36 | $42 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $42 | $288 | $534 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $44 | $44 | $44 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $67 | $327 | $587 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $42 | $59 | $76 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $125 | $437 | $748 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $318 | $318 | $318 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $296 | $346 | $395 |
| Esophageal motility study CPT 91010 • Gastroenterology | $155 | $158 | $161 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $92 | $92 | $92 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $49 | $57 | $65 |
| Auto-added CPT 00102 • General | $34 | $38 | $42 |
| Auto-added CPT 00104 • General | $34 | $38 | $42 |