| Tonsillectomy primary under age 12 CPT 42826 • ENT | $22 | $33 | $45 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $18 | $32 | $45 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $38 | $38 | $38 |
| Tympanostomy tube insertion CPT 69436 • ENT | $45 | $107 | $168 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $463 | $463 | $463 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $45 | $67 | $90 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $8 | $8 | $8 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $45 | $46 | $47 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $132 | $132 | $132 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $22 | $22 | $22 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $29 | $39 | $48 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $11 | $28 | $45 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $16 | $101 | $187 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $14 | $29 | $45 |
| Initial treatment first degree burn CPT 16000 • Emergency | $5 | $29 | $54 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $47 | $47 | $47 |
| Emergency department visit low severity CPT 99282 • Emergency | $27 | $37 | $47 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $7 | $7 | $7 |
| Emergency department visit high severity CPT 99284 • Emergency | $11 | $11 | $11 |
| Emergency department visit highest severity CPT 99285 • Emergency | $154 | $154 | $154 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $27 | $36 | $45 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $9 | $27 | $45 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $103 | $103 | $103 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $12 | $29 | $45 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $29 | $37 | $45 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $292 | $341 | $390 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $45 | $449 | $854 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $45 | $117 | $189 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $32 | $32 | $32 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $41 | $43 | $45 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $320 | $320 | $320 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $45 | $145 | $244 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $166 | $263 | $360 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $422 | $422 | $422 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $78 | $78 | $78 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $45 | $179 | $314 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $39 | $39 | $39 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $137 | $137 | $137 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $45 | $114 | $183 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $45 | $127 | $209 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $35 | $35 | $35 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $45 | $60 | $75 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $269 | $269 | $269 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $66 | $66 | $66 |
| Esophageal motility study CPT 91010 • Gastroenterology | $45 | $113 | $181 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $66 | $170 | $274 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $51 | $213 | $376 |
| Auto-added CPT 00102 • General | $45 | $45 | $45 |
| Auto-added CPT 00104 • General | $45 | $45 | $45 |