| Tonsillectomy primary under age 12 CPT 42826 • ENT | $30 | $77 | $125 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $103 | $155 | $206 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $30 | $31 | $32 |
| Tympanostomy tube insertion CPT 69436 • ENT | $155 | $155 | $156 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $614 | $614 | $614 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $30 | $274 | $519 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $6 | $6 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $30 | $76 | $121 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $125 | $151 | $178 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $46 | $68 | $91 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $17 | $17 | $17 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $11 | $60 | $109 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $52 | $52 | $52 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $25 | $27 | $30 |
| Initial treatment first degree burn CPT 16000 • Emergency | $7 | $18 | $30 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $65 | $70 | $76 |
| Emergency department visit low severity CPT 99282 • Emergency | $59 | $62 | $66 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $71 | $88 | $104 |
| Emergency department visit high severity CPT 99284 • Emergency | $18 | $87 | $156 |
| Emergency department visit highest severity CPT 99285 • Emergency | $26 | $111 | $195 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $30 | $83 | $136 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $11 | $20 | $30 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $15 | $83 | $150 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $18 | $24 | $30 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $30 | $30 | $30 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $77 | $230 | $384 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $30 | $565 | $1,101 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $30 | $65 | $100 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $228 | $228 | $228 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $30 | $70 | $110 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $47 | $47 | $47 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $30 | $146 | $262 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $53 | $53 | $53 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $68 | $68 | $68 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $31 | $31 | $31 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $206 | $308 | $411 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $37 | $37 | $37 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $90 | $90 | $90 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $196 | $196 | $196 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $443 | $443 | $443 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $30 | $137 | $244 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $30 | $30 | $30 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $30 | $61 | $92 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $40 | $40 | $40 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $243 | $243 | $243 |
| Esophageal motility study CPT 91010 • Gastroenterology | $22 | $26 | $30 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $79 | $79 | $80 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $82 | $82 | $82 |
| Auto-added CPT 00102 • General | $30 | $30 | $30 |
| Auto-added CPT 00104 • General | $30 | $30 | $30 |