| Tonsillectomy primary under age 12 CPT 42826 • ENT | $40 | $123 | $206 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $85 | $127 | $169 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $6 | $6 | $6 |
| Tympanostomy tube insertion CPT 69436 • ENT | $40 | $85 | $130 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $40 | $377 | $714 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $85 | $465 | $846 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $19 | $32 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $19 | $57 | $95 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $148 | $157 | $167 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $73 | $73 | $73 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $10 | $49 | $89 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $35 | $62 | $89 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $127 | $127 | $127 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $157 | $183 | $209 |
| Initial treatment first degree burn CPT 16000 • Emergency | $11 | $26 | $40 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $3 | $25 | $47 |
| Emergency department visit low severity CPT 99282 • Emergency | $17 | $26 | $34 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $65 | $65 | $66 |
| Emergency department visit high severity CPT 99284 • Emergency | $97 | $97 | $97 |
| Emergency department visit highest severity CPT 99285 • Emergency | $22 | $103 | $184 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $40 | $132 | $223 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $40 | $40 | $40 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $13 | $71 | $129 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $105 | $156 | $206 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $59 | $167 | $275 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $283 | $283 | $283 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $40 | $422 | $803 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $355 | $355 | $355 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $200 | $200 | $200 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $193 | $193 | $194 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $40 | $158 | $277 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $61 | $184 | $306 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $40 | $98 | $156 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $40 | $40 | $40 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $68 | $68 | $68 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $40 | $94 | $148 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $36 | $36 | $36 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $80 | $80 | $80 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $35 | $37 | $40 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $17 | $17 | $17 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $73 | $218 | $364 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $40 | $40 | $40 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $91 | $280 | $468 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $35 | $35 | $35 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $43 | $164 | $285 |
| Esophageal motility study CPT 91010 • Gastroenterology | $59 | $104 | $149 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $329 | $329 | $330 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $187 | $187 | $187 |
| Auto-added CPT 00102 • General | $40 | $40 | $40 |
| Auto-added CPT 00104 • General | $40 | $40 | $40 |