| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $10 | $230 | $471 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $8 | $144 | $294 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $7 | $95 | $207 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $40 | $57 | $70 |
| Tympanostomy tube insertion CPT 69436 • ENT | $5 | $116 | $248 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $28 | $864 | $1,863 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $33 | $641 | $1,047 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $31 | $41 | $53 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $4 | $81 | $134 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $7 | $106 | $180 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $48 | $67 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $30 | $58 | $87 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $30 | $53 | $76 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $8 | $112 | $279 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $9 | $122 | $288 |
| Initial treatment first degree burn CPT 16000 • Emergency | $30 | $56 | $76 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $10 | $26 | $52 |
| Emergency department visit low severity CPT 99282 • Emergency | $37 | $49 | $66 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $64 | $74 | $99 |
| Emergency department visit high severity CPT 99284 • Emergency | $103 | $155 | $325 |
| Emergency department visit highest severity CPT 99285 • Emergency | $5 | $135 | $205 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $9 | $158 | $333 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $4 | $82 | $168 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $5 | $117 | $171 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $9 | $146 | $296 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $127 | $291 | $548 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $201 | $336 | $555 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $5 | $395 | $1,167 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $219 | $486 | $720 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $7 | $214 | $324 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $7 | $183 | $286 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $10 | $382 | $873 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $9 | $274 | $438 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $10 | $314 | $518 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $425 | $520 | $635 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $9 | $160 | $306 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $253 | $384 | $598 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $9 | $256 | $450 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $238 | $382 | $628 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $95 | $359 | $641 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $285 | $500 | $706 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $8 | $328 | $461 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $171 | $491 | $890 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $8 | $885 | $2,652 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $9 | $303 | $461 |
| Esophageal motility study CPT 91010 • Gastroenterology | $89 | $162 | $248 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $82 | $342 | $676 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $74 | $184 | $463 |
| Auto-added CPT 00102 • General | $40 | $478 | $812 |
| Auto-added CPT 00104 • General | $40 | $476 | $749 |