| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $1,036.01 | $217.56 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $1,295.64 | $272.08 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,850.94 | $388.7 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $2,452.49 | $515.02 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $3,122.52 | $655.73 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $7,357.21 | $1,545.01 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $8,514.28 | $1,788 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $8,754.9 | $1,838.53 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $10,501 | $2,205.23 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $14,153 | $2,972.16 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $10,912 | $2,291.52 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $11,540 | $2,423.36 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $10,879 | $2,284.56 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $16,322 | $3,427.7 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $840.06 | $176.41 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $1,658.37 | $348.26 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $2,653.16 | $557.16 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $7,559.41 | $1,587.48 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $12,503 | $2,625.73 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $14,153 | $2,972.16 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $13,421 | $2,818.45 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $14,798 | $3,107.53 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $15,482 | $3,251.15 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $2,310.51 | $485.21 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $13,100 | $2,750.9 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $10,096 | $2,120.09 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $11,550 | $2,425.49 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $14,583 | $3,062.41 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $11,629 | $2,442.09 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $14,606 | $3,067.24 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $14,606 | $3,067.24 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $16,323 | $3,427.84 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $16,250 | $3,412.51 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $10,967 | $2,303.16 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $11,590 | $2,433.86 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $3,317.49 | $696.67 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $2,941.08 | $617.63 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $3,317.49 | $696.67 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $23,836 | $5,005.66 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $26,909 | $5,650.81 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $2,021.95 | $424.61 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $3,317.49 | $696.67 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $23,288 | $4,890.56 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $13,425 | $2,819.16 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $7,559.41 | $1,587.48 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $10,501 | $2,205.23 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $14,153 | $2,972.16 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $18,527 | $3,890.63 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $22,091 | $4,639.1 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $27,595 | $5,794.99 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $11,378 | $2,389.3 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $14,798 | $3,107.53 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $4,341.95 | $911.81 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $4,163.51 | $874.34 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $2,724.09 | $572.06 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $2,945.8 | $618.62 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $2,945.8 | $618.62 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $3,729.67 | $783.23 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $11,231 | $2,358.45 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $3,148.52 | $661.19 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $1,411.31 | $296.38 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,729.16 | $363.12 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,575.21 | $330.79 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $7,653.59 | $1,377.65 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $10,824 | $2,273.06 | — | — | — |
| 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 | $433.21 | $90.97 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $285.64 | $59.98 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $396.72 | $83.31 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $165.03 | $34.66 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $320.55 | $67.32 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $290.4 | $60.98 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $145.98 | $30.66 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $88.87 | $18.66 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $161.86 | $33.99 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $188.83 | $39.65 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $233.27 | $48.99 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $166.62 | $34.99 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $771.78 | $162.07 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $633.16 | $132.96 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $1,202.22 | $252.47 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $20,438 | $3,678.78 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $25,652 | $4,617.28 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $19,236 | $3,462.43 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $22,168 | $3,990.22 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $18,660 | $3,358.76 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $23,954 | $4,311.71 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $22,937 | $4,128.63 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $206,784 | $37,221 | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $156,780 | $28,220 | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $158,163 | $28,469 | — | — | — |
| Knee revision arthroplasty single component | CPT | 27486 | 0 | $191,808 | $34,525 | — | — | — |
| Knee revision arthroplasty all components | CPT | 27487 | 0 | $339,474 | $61,105 | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $107,657 | $19,378 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $115,941 | $20,869 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $68,350 | $12,303 | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $146,834 | $26,430 | — | — | — |
| 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 | $105,992 | $19,079 | — | — | — |
| 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 | $82,360 | $14,825 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $82,176 | $14,792 | — | — | — |
| 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 | $84,476 | $15,206 | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | $105,440 | $18,979 | — | — | — |
| Vaginal hysterectomy | CPT | 58260 | 0 | $65,062 | $11,711 | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $103,314 | $18,597 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $78,089 | $14,056 | — | — | — |
| 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 | — | — | — | — | — |
| Intravitreal injection | CPT | 67028 | 0 | $83,687 | $15,064 | — | — | — |
| Vitrectomy mechanical | CPT | 67042 | 0 | $62,292 | $11,213 | — | — | — |
| 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 | $82,549 | $17,335 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $99,999 | $21,000 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $99,999 | $21,000 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $52,717 | $11,070 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $46,884 | $9,845.65 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $52,717 | $11,070 | — | — | — |
