How much does a tonsil removal cost in 2021? | finder.com

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How much does a tonsil removal cost?

Compare payment options and costs for a tonsil removal

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If you're a candidate for a tonsil removal, costs vary significantly based on your insurance, where you live and the hospital or doctor you choose. Each procedure is assigned standardized, 5-digit CPT codes that hospitals and insurance companies use for billing purposes. Use the CPT code to compare prices for a tonsil removal before scheduling your appointment.

Average cost for a tonsil removal

If you have health insurance and use an in-network doctor, you can expect to pay $7,156 for a tonsil removal on average. If you don't have insurance or you choose an out-of-network doctor, the cost increases to $13,565.

Average costs are based on the primary cost of a tonsil removal in the 90201 ZIP code and don't factor in insurance costs like copays or deductibles, or additional fees often charged by doctors or hospitals — like medical supplies, facility fees and support services.

CPT code Procedure ZIP used Description In network total costs Out of network total costs
42820 Tonsil removal 90201 Removal of tonsils and adenoid glands patient younger than age 12 $7,156 $13,565

Related costs for a tonsil removal

CPT code Primary procedure Description In network cost Out of network cost
42820 Hospital (outpatient) Hospital outpatient facility (HOSPF) estimate for procedure code 42820 (in addition to your doctor's fee) $5,781 $10,540
Total primary & related costs $5,781 $10,540

Does health insurance cover a tonsil removal?

Most health insurance policies cover a tonsil removal if it's medically necessary and you've met your deductible and any coinsurance or copays specified in your policy. If you don't have health insurance, you may need to pay the full cost of a tonsil removal out of pocket. The exact amount your insurance pays for a tonsil removal comes down to your plan and the doctor or healthcare facility you're going to. For the most accurate idea of how much you'll pay out of pocket, contact your insurance company before booking a tonsil removal.

Does Medicare cover a tonsil removal?

It depends on your Medicare plan, but generally Medicare covers procedures like a tonsil removal that are considered medically necessary by your doctor.

  • Medicare Part A (Hospital Insurance) covers inpatient care in a hospital or skilled nursing facility following a hospital stay, so it typically won't cover a tonsil removal.
  • Medicare Part B (Medical Insurance) pays for emergency, urgent and outpatient care and some preventative services, which means Medicare likely covers a tonsil removal — but you'll be charged a 20% coinsurance.
  • Medicare Part C (Medicare Advantage) is a comprehensive plan that combines Part A, Part B and often Part D and should pay for a portion of a tonsil removal minus any deductible, copay or coinsurance.
  • Medicare Part D (Prescription Drugs) won't cover a tonsil removal, but it may help to pay for any medication you need as part of your recovery.

What affects the cost of a tonsil removal?

The price you'll pay for a tonsil removal varies based on factors like:

  • Your health insurance plan. Your coinsurance, copay and how much of your deductible you've met affects the amount you pay for a tonsil removal out of pocket, does as whether your doctor or anyone else involved is outside your network.
  • Your location. Where you live dictates which doctors or healthcare facilities you have access to for a tonsil removal. Urban areas are more competitive, which can drive down costs for a tonsil removal compared to rural areas.
  • Your doctor. Your doctor's experience and expertise affects how much they charge for a tonsil removal. And the cost may increase if complications arise during a tonsil removal and your doctor has to call in other medical professionals.
  • Additional fees. Your healthcare provider may charge associated fees that increase the overall cost of a tonsil removal.

How to cut your costs for a tonsil removal

In the leadup to a tonsil removal, confirm your copay, coinsurance and deductible with your insurer so you know how much you'll pay out of pocket.

  • Dip into your HSA, FSA or HRA. These tax-advantaged accounts can help you to cover out-of-pocket costs for a tonsil removal.
  • Ask about financial aid. If you can't afford to pay the average cost of $7,156 with or without insurance, most hospitals and clinics offer financial aid programs that include discounts or interest-free payment plans.
  • Explore outpatient centers. Outpatient facilities tend to charge less for medical procedures like a tonsil removal, though they're not an option for everyone.
  • Consider medical loans. A medical loan could help pay for anything your health insurance doesn't cover for a tonsil removal, like copays or coinsurance.
  • Compare doctors and hospitals. Lower the price of medical services by comparing in-network hospitals before you schedule a tonsil removal. The Centers for Medicare and Medicaid Services require hospitals and clinics to publish online price lists for common procedures, which may include costs for a tonsil removal.

Bottom line

The price of a tonsil removal is a major consideration for treatment whether you have health insurance or not. The amount you'll pay for a tonsil removal can vary between doctors, hospitals, locations and insurance plans, which is why it's worth comparing hospital prices.

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