| Tonsillectomy primary under age 12 CPT 42826 • ENT | $21 | $113 | $205 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $33 | $100 | $166 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $4 | $15 | $27 |
| Tympanostomy tube insertion CPT 69436 • ENT | $65 | $97 | $129 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $697 | $697 | $697 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $578 | $702 | $825 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $17 | $25 | $33 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $7 | $46 | $84 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $22 | $75 | $129 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $18 | $52 | $86 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $126 | $126 | $126 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $67 | $95 | $124 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $64 | $96 | $128 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $21 | $113 | $205 |
| Initial treatment first degree burn CPT 16000 • Emergency | $8 | $24 | $40 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $49 | $49 | $50 |
| Emergency department visit low severity CPT 99282 • Emergency | $5 | $5 | $5 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $5 | $31 | $56 |
| Emergency department visit high severity CPT 99284 • Emergency | $15 | $15 | $15 |
| Emergency department visit highest severity CPT 99285 • Emergency | $146 | $151 | $157 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $33 | $124 | $216 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $9 | $25 | $40 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $56 | $84 | $112 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $12 | $122 | $232 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $271 | $271 | $271 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $17 | $94 | $171 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $40 | $94 | $148 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $37 | $111 | $185 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $270 | $270 | $270 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $259 | $259 | $260 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $40 | $40 | $40 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $183 | $274 | $365 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $44 | $44 | $44 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $65 | $65 | $65 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $40 | $73 | $106 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $31 | $31 | $31 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $53 | $53 | $53 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $47 | $47 | $47 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $56 | $215 | $373 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $54 | $132 | $209 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $174 | $273 | $371 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $212 | $212 | $212 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $227 | $369 | $512 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $43 | $164 | $285 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $354 | $413 | $472 |
| Esophageal motility study CPT 91010 • Gastroenterology | $40 | $93 | $146 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $364 | $364 | $364 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $50 | $80 | $110 |
| Auto-added CPT 00102 • General | $40 | $40 | $40 |
| Auto-added CPT 00104 • General | $40 | $40 | $40 |