| Tonsillectomy primary under age 12 CPT 42826 • ENT | $45 | $105 | $164 |
| Adenoidectomy primary under age 12 CPT 42830 • ENT | $45 | $119 | $193 |
| Removal impacted cerumen unilateral CPT 69210 • ENT | $3 | $3 | $3 |
| Tympanostomy tube insertion CPT 69436 • ENT | $45 | $58 | $71 |
| Tympanoplasty without mastoidectomy CPT 69631 • ENT | $549 | $549 | $549 |
| Tympanoplasty with mastoidectomy CPT 69633 • ENT | $45 | $487 | $929 |
| Comprehensive audiometry evaluation CPT 92557 • ENT | $6 | $18 | $30 |
| Incision and drainage abscess simple CPT 10060 • Emergency | $8 | $27 | $45 |
| Incision and drainage abscess complicated CPT 10061 • Emergency | $177 | $177 | $177 |
| Simple wound repair up to 2.5cm CPT 12001 • Emergency | $6 | $25 | $45 |
| Simple wound repair 2.6-7.5cm CPT 12002 • Emergency | $14 | $29 | $45 |
| Simple wound repair face 2.5cm or less CPT 12011 • Emergency | $45 | $45 | $45 |
| Intermediate wound repair 2.5cm or less CPT 12031 • Emergency | $135 | $168 | $202 |
| Intermediate wound repair face 2.5cm or less CPT 12051 • Emergency | $45 | $105 | $165 |
| Initial treatment first degree burn CPT 16000 • Emergency | $12 | $28 | $45 |
| Emergency department visit self-limited problem CPT 99281 • Emergency | $18 | $34 | $49 |
| Emergency department visit low severity CPT 99282 • Emergency | $18 | $18 | $18 |
| Emergency department visit moderate severity CPT 99283 • Emergency | $57 | $57 | $57 |
| Emergency department visit high severity CPT 99284 • Emergency | $50 | $79 | $108 |
| Emergency department visit highest severity CPT 99285 • Emergency | $22 | $92 | $161 |
| Critical care first 30-74 minutes CPT 99291 • Emergency | $19 | $32 | $45 |
| Critical care each additional 30 minutes CPT 99292 • Emergency | $96 | $96 | $96 |
| Esophagoscopy rigid diagnostic CPT 43191 • Gastroenterology | $22 | $22 | $22 |
| Upper GI endoscopy diagnostic CPT 43235 • Gastroenterology | $45 | $45 | $45 |
| Upper GI endoscopy with biopsy CPT 43239 • Gastroenterology | $27 | $36 | $45 |
| Upper GI endoscopy with foreign body removal CPT 43247 • Gastroenterology | $34 | $176 | $317 |
| Upper GI endoscopy with balloon dilation CPT 43249 • Gastroenterology | $22 | $34 | $45 |
| Upper GI endoscopy with polypectomy by snare CPT 43251 • Gastroenterology | $45 | $62 | $79 |
| Upper GI endoscopy with stent placement CPT 43257 • Gastroenterology | $167 | $167 | $167 |
| Upper GI endoscopy with endoscopic ultrasound CPT 43259 • Gastroenterology | $45 | $103 | $162 |
| ERCP diagnostic CPT 43260 • Gastroenterology | $154 | $154 | $154 |
| ERCP with sphincterotomy CPT 43262 • Gastroenterology | $45 | $45 | $45 |
| ERCP with removal of stones CPT 43264 • Gastroenterology | $45 | $196 | $348 |
| ERCP with stent placement CPT 43274 • Gastroenterology | $89 | $89 | $89 |
| Colonoscopy through stoma diagnostic CPT 44388 • Gastroenterology | $198 | $198 | $198 |
| Colonoscopy through stoma with biopsy CPT 44389 • Gastroenterology | $45 | $64 | $83 |
| Flexible sigmoidoscopy diagnostic CPT 45330 • Gastroenterology | $11 | $11 | $11 |
| Colonoscopy diagnostic CPT 45378 • Gastroenterology | $45 | $111 | $178 |
| Colonoscopy with biopsy CPT 45380 • Gastroenterology | $275 | $275 | $275 |
| Colonoscopy with submucosal injection CPT 45381 • Gastroenterology | $263 | $263 | $263 |
| Colonoscopy with lesion removal by hot biopsy CPT 45384 • Gastroenterology | $45 | $45 | $45 |
| Colonoscopy with polypectomy by snare CPT 45385 • Gastroenterology | $45 | $114 | $183 |
| Colonoscopy with balloon dilation CPT 45386 • Gastroenterology | $45 | $124 | $204 |
| Colonoscopy with ablation of tumor or polyp CPT 45388 • Gastroenterology | $260 | $260 | $260 |
| Colonoscopy with endoscopic mucosal resection CPT 45390 • Gastroenterology | $48 | $48 | $48 |
| Esophageal motility study CPT 91010 • Gastroenterology | $45 | $65 | $85 |
| Esophageal motility study with acid reflux CPT 91035 • Gastroenterology | $284 | $297 | $310 |
| Esophageal pH monitoring 24 hours CPT 91038 • Gastroenterology | $306 | $330 | $353 |
| Auto-added CPT 00102 • General | $45 | $45 | $45 |
| Auto-added CPT 00104 • General | $45 | $45 | $45 |