| Tonsillectomy and adenoidectomy age 12 or older CPT 42821 • ENT | $80 | $185 | $290 |
| Tonsillectomy primary under age 12 CPT 42826 • ENT | $80 | $162 | $244 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $80 | $142 | $203 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $45 | $63 | $80 |
| Tympanostomy tube insertion CPT 69436 • ENT | $80 | $116 | $152 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $80 | $460 | $841 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $80 | $537 | $993 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $30 | $55 | $80 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $80 | $100 | $120 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $80 | $152 | $202 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $80 | $84 | $88 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $55 | $68 | $80 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $52 | $69 | $80 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $80 | $111 | $143 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $80 | $173 | $266 |
| Initial treatment first degree burn CPT 16000 • Emergency | $75 | $77 | $80 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $11 | $45 | $80 |
| Emergency department visit low severity CPT 99282 • Emergency | $40 | $60 | $80 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $68 | $77 | $83 |
| Emergency department visit high severity CPT 99284 • Emergency | $80 | $117 | $157 |
| Emergency department visit highest severity CPT 99285 • Emergency | $80 | $148 | $197 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $80 | $178 | $253 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $80 | $114 | $149 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $80 | $113 | $146 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $80 | $97 | $115 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $80 | $215 | $351 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $80 | $219 | $358 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $80 | $536 | $991 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $80 | $132 | $183 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $80 | $149 | $218 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $80 | $145 | $211 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $80 | $191 | $301 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $80 | $207 | $333 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $80 | $210 | $340 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $80 | $256 | $432 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $80 | $188 | $295 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $80 | $232 | $384 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $173 | $173 | $173 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $80 | $126 | $172 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $80 | $243 | $405 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $80 | $134 | $187 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $80 | $268 | $455 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $80 | $253 | $426 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $80 | $323 | $566 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $2,241 | $2,241 | $2,241 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $310 | $310 | $310 |
| Esophageal motility study CPT 91010 • Gastroenterology | $61 | $71 | $80 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $77 | $78 | $80 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $80 | $227 | $374 |
| Auto-added CPT 00102 • General | $65 | $65 | $65 |