| Tonsillectomy primary under age 12 CPT 42826 • ENT | $25 | $35 | $45 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $45 | $69 | $94 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $15 | $30 | $45 |
| Tympanostomy tube insertion CPT 69436 • ENT | $14 | $29 | $45 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $877 | $877 | $877 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $45 | $360 | $674 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $20 | $34 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $44 | $60 | $76 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $89 | $117 | $144 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $30 | $51 | $71 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $10 | $10 | $10 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $45 | $50 | $55 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $111 | $111 | $111 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $29 | $37 | $45 |
| Initial treatment first degree burn CPT 16000 • Emergency | $7 | $26 | $44 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $8 | $12 | $17 |
| Emergency department visit low severity CPT 99282 • Emergency | $28 | $47 | $66 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $7 | $31 | $55 |
| Emergency department visit high severity CPT 99284 • Emergency | $95 | $110 | $125 |
| Emergency department visit highest severity CPT 99285 • Emergency | $103 | $120 | $137 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $45 | $128 | $212 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $9 | $9 | $9 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $15 | $84 | $153 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $12 | $28 | $45 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $45 | $110 | $174 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $37 | $195 | $353 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $45 | $369 | $693 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $45 | $257 | $470 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $212 | $212 | $212 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $33 | $39 | $45 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $62 | $177 | $292 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $45 | $47 | $49 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $174 | $252 | $330 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $221 | $221 | $221 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $150 | $150 | $150 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $33 | $206 | $380 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $8 | $8 | $8 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $135 | $237 | $338 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $36 | $36 | $36 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $33 | $39 | $45 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $20 | $33 | $45 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $2,017 | $2,352 | $2,688 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $48 | $186 | $324 |
| Esophageal motility study CPT 91010 • Gastroenterology | $45 | $94 | $144 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $66 | $124 | $183 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $54 | $181 | $308 |
| Auto-added CPT 00102 • General | $48 | $48 | $48 |
| Auto-added CPT 00104 • General | $40 | $43 | $45 |