| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $511.92 | $153.58 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,964.52 | $589.36 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $2,482.92 | $744.88 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $3,257.28 | $977.18 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $4,121.28 | $1,236.38 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $5,740.2 | $1,722.06 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $8,094 | $2,428.2 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $8,606 | $2,581.8 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $12,165 | $3,649.5 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $10,290 | $3,087 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $11,116 | $3,334.8 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $9,199 | $2,759.7 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $17,026 | $5,107.8 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $788 | $236.4 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $1,125 | $337.5 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $1,412 | $423.6 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $8,053 | $2,415.9 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $8,896 | $2,668.8 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $9,483 | $2,844.9 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $8,768 | $2,630.4 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $7,752.64 | $2,325.79 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $8,753.31 | $2,625.99 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $1,045 | $313.5 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $16,764 | $5,029.2 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $16,764 | $5,029.2 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $16,764 | $5,029.2 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $10,718 | $3,215.4 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $10,112 | $3,033.6 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $10,718 | $3,215.4 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $9,872 | $2,961.6 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $17,026 | $5,107.8 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $17,018 | $5,105.4 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $8,050 | $2,415 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $8,553 | $2,565.9 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $2,233 | $669.9 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $2,090 | $627 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $2,217 | $665.1 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $8,197 | $2,459.1 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $16,333 | $4,899.9 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $1,833 | $549.9 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $2,492 | $747.6 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $8,545 | $2,563.5 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $15,043 | $4,512.97 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $8,094 | $2,428.2 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $8,896 | $2,668.8 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $10,086 | $3,025.8 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $16,141 | $4,842.3 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $17,449 | $5,234.7 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $19,603 | $5,880.9 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $10,112 | $3,033.6 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $10,846 | $3,253.8 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $3,890 | $1,167 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $3,314 | $994.2 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $2,920 | $876 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $2,211 | $663.3 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $2,319 | $695.7 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $4,036 | $1,210.8 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $2,856 | $856.8 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,398 | $419.4 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $1,219 | $365.7 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,508 | $452.4 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,263 | $378.9 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $520 | $156 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $8,583 | $2,574.9 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $5,009 | $1,502.7 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $5,697 | $1,709.1 | — | — | — |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 0 | — | — | — | — | — |
| COPD w MCC | MS-DRG | 190 | 0 | — | — | — | — | — |
| COPD w CC | MS-DRG | 191 | 0 | — | — | — | — | — |
| COPD w/o CC/MCC | MS-DRG | 192 | 0 | — | — | — | — | — |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 0 | — | — | — | — | — |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 0 | — | — | — | — | — |
| AMI discharged alive w MCC | MS-DRG | 280 | 0 | — | — | — | — | — |
| AMI discharged alive w CC | MS-DRG | 281 | 0 | — | — | — | — | — |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 0 | — | — | — | — | — |
| Heart failure & shock w MCC | MS-DRG | 291 | 0 | — | — | — | — | — |
| Heart failure & shock w CC | MS-DRG | 292 | 0 | — | — | — | — | — |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 0 | — | — | — | — | — |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 0 | — | — | — | — | — |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 0 | — | — | — | — | — |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 0 | — | — | — | — | — |
| GI hemorrhage w CC | MS-DRG | 378 | 0 | — | — | — | — | — |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 0 | — | — | — | — | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 0 | — | — | — | — | — |
| Fractures of femur w/o MCC | MS-DRG | 533 | 0 | — | — | — | — | — |
| Kidney/UTI w MCC | MS-DRG | 689 | 0 | — | — | — | — | — |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 0 | — | — | — | — | — |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 0 | — | — | — | — | — |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 0 | — | — | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $433 | $129.9 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $286 | $85.8 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $394 | $118.2 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $163 | $48.9 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $320 | $96 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $288 | $86.4 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $173.33 | $52 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $146 | $43.8 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $89 | $26.7 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $161 | $48.3 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $193 | $57.9 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $232 | $69.6 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $166 | $49.8 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $224 | $67.2 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $148.36 | $44.51 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $633 | $189.9 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $807 | $242.1 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $18,335 | $2,750.32 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $37,853 | $5,677.89 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $21,648 | $3,247.18 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $21,218 | $3,182.76 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $16,210 | $2,431.51 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $32,078 | $4,811.69 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $36,858 | $5,528.67 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $156,743 | $23,511 | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $119,664 | $17,950 | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $128,643 | $19,296 | — | — | — |
| Knee revision arthroplasty single component | CPT | 27486 | 0 | $69,141 | $10,371 | — | — | — |
| Knee revision arthroplasty all components | CPT | 27487 | 0 | $133,672 | $20,051 | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $110,237 | $16,536 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $124,386 | $18,658 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $73,628 | $11,044 | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $160,622 | $24,093 | — | — | — |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 0 | — | — | — | — | — |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 0 | — | — | — | — | — |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 0 | — | — | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $121,840 | $18,276 | — | — | — |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 0 | — | — | — | — | — |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 0 | — | — | — | — | — |
| Major joint replacement w MCC | MS-DRG | 469 | 0 | — | — | — | — | — |
| Major joint replacement w/o MCC | MS-DRG | 470 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $59,120 | $8,867.94 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $48,308 | $7,246.24 | — | — | — |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 0 | — | — | — | — | — |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 0 | — | — | — | — | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 0 | — | — | — | — | — |
| Lap inguinal hernia repair | CPT | 49650 | 0 | $80,913 | $12,137 | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | $49,588 | $7,438.19 | — | — | — |
| Vaginal hysterectomy | CPT | 58260 | 0 | $53,528 | $8,029.18 | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | $69,956 | $10,493 | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $83,998 | $12,600 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $79,017 | $11,852 | — | — | — |
| OR procedure for obesity w MCC | MS-DRG | 619 | 0 | — | — | — | — | — |
| OR procedure for obesity w CC | MS-DRG | 620 | 0 | — | — | — | — | — |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 0 | — | — | — | — | — |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 0 | — | — | — | — | — |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 0 | — | — | — | — | — |
| PCI single major coronary artery | CPT | 92920 | 0 | $42,986 | $12,896 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $45,253 | $13,576 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $73,486 | $22,046 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $12,504 | $3,751.2 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $34,403 | $10,321 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $42,654 | $12,796 | — | — | — |
