NOVANT HEALTH FORSYTH MEDICAL CENTER· WINSTON-SALEM, NC

HospitalCMS 4/5

3333 SILAS CREEK PARKWAY, WINSTON-SALEM, NC 27103

Procedures offered

940 total

Procedure	Min	Avg	Max
Tonsillectomy primary under age 12 CPT 42826 • ENT	$247	$348	$599
Adenoidectomy primary under age 12 CPT 42830 • ENT	$128	$252	$498
Removal impacted cerumen unilateral CPT 69210 • ENT	$45	$60	$112
Tympanostomy tube insertion CPT 69436 • ENT	$95	$193	$378
Tympanoplasty without mastoidectomy CPT 69631 • ENT	$825	$1,189	$1,981
Tympanoplasty with mastoidectomy CPT 69633 • ENT	$982	$1,361	$1,867
Comprehensive audiometry evaluation CPT 92557 • ENT	$29	$50	$89
Incision and drainage abscess simple CPT 10060 • Emergency	$72	$148	$254
Incision and drainage abscess complicated CPT 10061 • Emergency	$127	$219	$322
Simple wound repair up to 2.5cm CPT 12001 • Emergency	$49	$117	$152
Simple wound repair 2.6-7.5cm CPT 12002 • Emergency	$64	$143	$173
Simple wound repair face 2.5cm or less CPT 12011 • Emergency	$60	$125	$170
Intermediate wound repair 2.5cm or less CPT 12031 • Emergency	$191	$258	$318
Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency	$177	$337	$587
Initial treatment first degree burn CPT 16000 • Emergency	$45	$86	$140
Emergency department visit self-limited problem CPT 99281 • Emergency	$11	$18	$33
Emergency department visit low severity CPT 99282 • Emergency	$39	$45	$57
Emergency department visit moderate severity CPT 99283 • Emergency	$53	$71	$104
Emergency department visit high severity CPT 99284 • Emergency	$113	$159	$289
Emergency department visit highest severity CPT 99285 • Emergency	$161	$228	$425
Critical care first 30-74 minutes CPT 99291 • Emergency	$219	$275	$311
Critical care each additional 30 minutes CPT 99292 • Emergency	$89	$118	$131
Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology	$150	$187	$250
Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology	$151	$354	$726
Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology	$180	$434	$930
Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology	$191	$432	$938
Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology	$89	$736	$2,744
Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology	$208	$507	$1,223
Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology	$252	$389	$777
Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology	$245	$335	$517
ERCP diagnostic CPT 43260 • Gastroenterology	$326	$426	$740
ERCP with sphincterotomy CPT 43262 • Gastroenterology	$385	$560	$821
ERCP with removal of stones CPT 43264 • Gastroenterology	$368	$502	$835
ERCP with stent placement CPT 43274 • Gastroenterology	$499	$680	$1,062
Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology	$96	$294	$581
Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology	$100	$503	$1,224
Colonoscopy diagnostic CPT 45378 • Gastroenterology	$350	$461	$822
Colonoscopy with biopsy CPT 45380 • Gastroenterology	$291	$574	$1,061
Colonoscopy with submucosal injection CPT 45381 • Gastroenterology	$435	$601	$1,083
Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology	$222	$485	$904
Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology	$147	$551	$1,100
Colonoscopy with balloon dilation CPT 45386 • Gastroenterology	$206	$732	$1,512
Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology	$293	$1,722	$6,247
Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology	$350	$464	$762
Esophageal motility study CPT 91010 • Gastroenterology	$59	$229	$552
Esophageal motility study with acid reflux CPT 91035 • Gastroenterology	$82	$505	$1,177
Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology	$80	$299	$616
Auto-added CPT 00102 • General	$42	$219	$713
Auto-added CPT 00104 • General	$42	$131	$361
Auto-added CPT 00120 • General	$57	$333	$611