| behavioral |
| Psychoses | MS-DRG | 885 | 3 | — | — | $11,893 | $11,893 | $14,272 |
| emergency |
| ED visit level 1 | CPT | 99281 | 6 | $477 | $333.9 | $90.82 | $372.8 | $3,263 |
| ED visit level 2 | CPT | 99282 | 6 | $906 | $634.2 | $164.61 | $724.8 | $5,714 |
| ED visit level 3 | CPT | 99283 | 6 | $1,470 | $1,029 | $289.71 | $1,176 | $7,508 |
| ED visit level 4 | CPT | 99284 | 7 | $2,313 | $1,619.1 | $444.03 | $1,630.82 | $12,242 |
| ED visit level 5 | CPT | 99285 | 6 | $3,914 | $2,739.8 | $653.13 | $3,072.8 | $16,976 |
| Critical care, first hour | CPT | 99291 | 6 | $8,471 | $5,929.7 | $866.49 | $6,620.4 | $19,587 |
| imaging |
| CT head without contrast | CPT | 70450 | 7 | $3,744 | $2,620.8 | $119.3 | $324.7 | $2,995.2 |
| CT head with contrast | CPT | 70460 | 6 | $4,886 | $3,420.2 | $223.35 | $535.83 | $3,908.8 |
| CT head with and without contrast | CPT | 70470 | 6 | $6,025 | $4,217.5 | $223.35 | $535.83 | $4,820 |
| CT neck with contrast | CPT | 70491 | 6 | $4,228 | $2,959.6 | $223.35 | $535.83 | $3,382.4 |
| MRI brain without contrast | CPT | 70551 | 6 | $7,264 | $5,084.8 | $287.87 | $1,159.44 | $5,811.2 |
| MRI brain with contrast | CPT | 70552 | 6 | $7,554 | $5,287.8 | $460.49 | $1,159.44 | $6,043.2 |
| MRI brain with and without contrast | CPT | 70553 | 6 | $7,918 | $5,542.6 | $460.49 | $1,159.44 | $6,334.4 |
| Chest X-ray single view | CPT | 71045 | 8 | $508 | $355.6 | $20.32 | $102.15 | $406.4 |
| Chest X-ray 2 views | CPT | 71046 | 7 | $660 | $462 | $31.6 | $121.44 | $528 |
| Chest X-ray 3 views | CPT | 71047 | 7 | $812 | $568.4 | $40.56 | $121.44 | $649.6 |
| CT chest without contrast | CPT | 71250 | 6 | $3,816 | $2,671.2 | $136.31 | $537.94 | $3,052.8 |
| CT chest with contrast | CPT | 71260 | 6 | $7,262 | $5,083.4 | $223.35 | $555.11 | $5,809.6 |
| CT chest with and without contrast | CPT | 71270 | 6 | $8,206 | $5,744.2 | $223.35 | $555.11 | $6,564.8 |
| MRI chest without contrast | CPT | 71550 | 6 | $3,485 | $2,439.5 | $287.87 | $1,159.44 | $2,788 |
| MRI chest with contrast | CPT | 71551 | 6 | $7,574 | $5,301.8 | $894.63 | $1,159.44 | $6,059.2 |
| MRI chest with and without contrast | CPT | 71552 | 6 | $8,171 | $5,719.7 | $460.49 | $1,159.44 | $6,536.8 |
| Lumbosacral spine X-ray | CPT | 72100 | 7 | $1,062 | $743.4 | $49.97 | $152.37 | $849.6 |
| CT cervical spine without contrast | CPT | 72125 | 7 | $5,078 | $3,554.6 | $136.31 | $383.87 | $4,062.4 |
| CT thoracic spine without contrast | CPT | 72128 | 6 | $4,848 | $3,393.6 | $136.31 | $537.94 | $3,878.4 |
| CT lumbar spine without contrast | CPT | 72131 | 6 | $5,530 | $3,871 | $136.31 | $537.94 | $4,424 |
| MRI cervical spine without contrast | CPT | 72141 | 6 | $8,837 | $6,185.9 | $287.87 | $1,159.44 | $7,069.6 |
| MRI thoracic spine without contrast | CPT | 72146 | 6 | $8,087 | $5,660.9 | $287.87 | $1,159.44 | $6,469.6 |
| MRI lumbar spine without contrast | CPT | 72148 | 6 | $6,450 | $4,515 | $287.87 | $1,159.44 | $5,160 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 6 | $9,352 | $6,546.4 | $460.49 | $1,159.44 | $7,481.6 |
| MRI cervical spine with and without contrast | CPT | 72156 | 6 | $14,757 | $10,330 | $460.49 | $1,159.44 | $11,806 |
| MRI lumbar spine with contrast | CPT | 72158 | 6 | $10,773 | $7,541.1 | $460.49 | $1,159.44 | $8,618.4 |
| CT pelvis without contrast | CPT | 72192 | 6 | $3,817 | $2,671.9 | $136.31 | $532.52 | $3,053.6 |
| CT pelvis with contrast | CPT | 72193 | 6 | $7,300 | $5,110 | $223.35 | $555.11 | $5,840 |
| CT abdomen without contrast | CPT | 74150 | 6 | $2,664 | $1,864.8 | $136.31 | $530.08 | $2,131.2 |
| CT abdomen with contrast | CPT | 74160 | 6 | $4,106 | $2,874.2 | $223.35 | $555.11 | $3,284.8 |
| CT abdomen with and without contrast | CPT | 74170 | 6 | $4,771 | $3,339.7 | $223.35 | $555.11 | $3,816.8 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 6 | $5,396 | $3,777.2 | $205.9 | $409.04 | $4,316.8 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 7 | $8,158 | $5,710.6 | $291.04 | $552.59 | $6,526.4 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 6 | $6,492 | $4,544.4 | $367.13 | $622.3 | $5,193.6 |
| MRI abdomen without contrast | CPT | 74181 | 6 | $5,170 | $3,619 | $287.87 | $1,253.72 | $4,136 |
| MRI abdomen with and without contrast | CPT | 74183 | 6 | $8,634 | $6,043.8 | $460.49 | $1,253.72 | $6,907.2 |
| Abdominal ultrasound complete | CPT | 76700 | 7 | $2,229 | $1,560.3 | $136.31 | $344.61 | $1,783.2 |
| Abdominal ultrasound limited | CPT | 76705 | 7 | $1,716 | $1,201.2 | $100.2 | $301.74 | $1,372.8 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 7 | $1,869 | $1,308.3 | $133.15 | $344.61 | $1,495.2 |
| Obstetric ultrasound first trimester | CPT | 76801 | 7 | $950 | $665 | $90.18 | $249.46 | $760 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 7 | $1,101 | $770.7 | $136.31 | $344.61 | $880.8 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 7 | $1,276 | $893.2 | $186.79 | $386.03 | $1,176.71 |
| Transvaginal ultrasound | CPT | 76830 | 8 | $1,244 | $870.8 | $70.83 | $245.54 | $995.2 |
| Pelvic ultrasound complete | CPT | 76856 | 8 | $2,063 | $1,444.1 | $67.93 | $244.94 | $1,650.4 |
| Scrotal ultrasound | CPT | 76870 | 7 | $1,893 | $1,325.1 | $107.95 | $312.5 | $1,514.4 |
| Diagnostic mammography bilateral | CPT | 77066 | 7 | $624 | $436.8 | $137.2 | $418.02 | $1,116.67 |
| Screening mammography bilateral | CPT | 77067 | 7 | $655 | $458.5 | $113.42 | $345.2 | $922.19 |
| EKG tracing only | CPT | 93005 | 5 | $639 | $447.3 | $27.05 | $83.56 | $511.2 |
| Transthoracic echocardiogram complete | CPT | 93306 | 5 | $6,681 | $4,676.7 | $275.72 | $724.87 | $5,344.8 |
| Transthoracic echocardiogram | CPT | 93307 | 5 | $2,564 | $1,794.8 | $247.6 | $345.44 | $2,051.2 |
| Stress echocardiogram | CPT | 93350 | 5 | $4,209 | $2,946.3 | $158.55 | $604.06 | $3,367.2 |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 3 | — | — | $17,596 | $17,596 | $21,115 |
| COPD w MCC | MS-DRG | 190 | 3 | — | — | $10,832 | $10,832 | $12,998 |
| COPD w CC | MS-DRG | 191 | 3 | — | — | $8,574.11 | $8,574.11 | $10,289 |
| COPD w/o CC/MCC | MS-DRG | 192 | 3 | — | — | $6,809.57 | $6,809.57 | $8,171.48 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 3 | — | — | $8,385.65 | $8,385.65 | $10,063 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 3 | — | — | $6,529.23 | $6,529.23 | $7,835.08 |
| AMI discharged alive w MCC | MS-DRG | 280 | 3 | — | — | $15,541 | $15,541 | $18,650 |
| AMI discharged alive w CC | MS-DRG | 281 | 3 | — | — | $9,033.52 | $9,033.52 | $10,840 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 3 | — | — | $7,096.47 | $7,096.47 | $8,515.76 |
| Heart failure & shock w MCC | MS-DRG | 291 | 3 | — | — | $12,866 | $12,866 | $15,440 |
| Heart failure & shock w CC | MS-DRG | 292 | 3 | — | — | $8,686.62 | $8,686.62 | $10,424 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 3 | — | — | $6,412.97 | $6,412.97 | $7,695.56 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 3 | — | — | $11,539 | $11,539 | $13,847 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 3 | — | — | $7,320.56 | $7,320.56 | $8,784.67 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 3 | — | — | $5,529.77 | $5,529.77 | $6,635.72 |
| GI hemorrhage w CC | MS-DRG | 378 | 3 | — | — | $9,606.39 | $9,606.39 | $11,528 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 3 | — | — | $6,267.65 | $6,267.65 | $7,521.18 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 3 | — | — | $7,461.19 | $7,461.19 | $8,953.43 |
| Fractures of femur w/o MCC | MS-DRG | 533 | 3 | — | — | $13,539 | $13,539 | $16,246 |
| Kidney/UTI w MCC | MS-DRG | 689 | 3 | — | — | $10,714 | $10,714 | $12,856 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 3 | — | — | $7,721.84 | $7,721.84 | $9,266.21 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 3 | — | — | $17,810 | $17,810 | $21,372 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 3 | — | — | $9,872.66 | $9,872.66 | $11,847 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 7 | $443 | $310.1 | $8.46 | $22.69 | $354.4 |
| General health panel | CPT | 80050 | 4 | $1,087 | $760.9 | $115.33 | $238.51 | $869.6 |
| Electrolyte panel | CPT | 80051 | 7 | $290 | $203 | $7.01 | $18.79 | $232 |
| Comprehensive metabolic panel | CPT | 80053 | 8 | $474 | $331.8 | $10.56 | $22.21 | $379.2 |
| Lipid panel | CPT | 80061 | 7 | $315 | $220.5 | $13.39 | $35.91 | $252 |
| Renal function panel | CPT | 80069 | 7 | $327 | $228.9 | $8.68 | $23.28 | $261.6 |
| Hepatic function panel | CPT | 80076 | 7 | $372 | $260.4 | $8.17 | $21.91 | $297.6 |
| Urinalysis non-automated | CPT | 81002 | 7 | $97 | $67.9 | $3.48 | $8.2 | $77.6 |
| Urinalysis automated | CPT | 81003 | 7 | $92 | $64.4 | $2.25 | $5.81 | $73.6 |
| Glucose quantitative | CPT | 82947 | 7 | $208 | $145.6 | $3.93 | $13.39 | $166.4 |
| Hemoglobin A1c | CPT | 83036 | 7 | $41 | $28.7 | $9.71 | $19.2 | $107.28 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 7 | $443 | $310.1 | $6.4 | $35.53 | $354.4 |
| Complete blood count with automated differential | CPT | 85025 | 8 | $224 | $156.8 | $7.75 | $16.23 | $179.2 |
| Complete blood count without differential | CPT | 85027 | 7 | $224 | $156.8 | $6.47 | $17.34 | $179.2 |
| Urine culture bacterial | CPT | 87086 | 7 | $309 | $216.3 | $8.07 | $21.65 | $247.2 |
| Urine culture identification | CPT | 87088 | 7 | $28.35 | $19.85 | $6.99 | $21.68 | $79.53 |
| Tissue exam by pathologist level IV | CPT | 88305 | 7 | $350 | $245 | $20.8 | $74.32 | $280 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 8 | $430 | $301 | $37.61 | $299.71 | $5,174 |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 2 | — | — | $1,795.64 | $3,143.82 | $7,701 |
| Vaginal delivery only | CPT | 59409 | 6 | — | — | $897.83 | $3,609.58 | $9,831 |
| Vaginal delivery with postpartum | CPT | 59410 | 3 | — | — | $2,166.82 | $3,143.82 | $7,701 |
| Routine obstetric care with C-section | CPT | 59510 | 2 | — | — | $1,795.75 | $3,592.94 | $7,701 |
| C-section delivery only | CPT | 59514 | 2 | — | — | $898.55 | $3,592.94 | $7,701 |
| C-section with postpartum | CPT | 59515 | 3 | — | — | $2,476.36 | $5,311 | $7,701 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 2 | $349 | $244.3 | $103 | $145.6 | $279.2 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 2 | $305 | $213.5 | $103 | $193.6 | $244 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 2 | $458 | $320.6 | $103 | $248 | $366.4 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 2 | $810 | $567 | $103 | $144 | $648 |
| Office visit, established patient, 5 min | CPT | 99211 | 2 | $349 | $244.3 | $100 | $104 | $279.2 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 2 | $171 | $119.7 | $103 | $136.8 | $144 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 2 | $217 | $151.9 | $103 | $144 | $173.6 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 2 | $328 | $229.6 | $103 | $198 | $262.4 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 2 | $578 | $404.6 | $103 | $144 | $462.4 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 6 | — | — | $369.7 | $1,984.2 | $7,244 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 6 | — | — | $386.3 | $2,655.32 | $7,244 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 6 | — | — | $90.28 | $1,984.2 | $6,468 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 6 | — | — | $119.15 | $1,984.2 | $6,468 |
| Colonoscopy diagnostic | CPT | 45378 | 6 | — | — | $487 | $2,655.32 | $7,244 |
| Colonoscopy with biopsy | CPT | 45380 | 6 | — | — | $544.73 | $2,655.32 | $7,244 |
| Colonoscopy with polyp removal | CPT | 45385 | 6 | — | — | $660.19 | $2,655.32 | $7,244 |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 6 | — | — | $1,428.05 | $11,893 | $20,698 |
| PCI w drug-eluting stent w MCC | MS-DRG | 246 | 5 | — | — | $9,689 | $28,401 | $35,520 |
| PCI w drug-eluting stent w/o MCC | MS-DRG | 247 | 5 | — | — | $9,689 | $23,612 | $31,715 |
| Hip hemiarthroplasty | CPT | 27125 | 6 | — | — | $1,719.57 | $8,622.5 | $18,486 |
| Total hip replacement | CPT | 27130 | 6 | — | — | $2,456.53 | $11,893 | $20,698 |
| Total knee replacement | CPT | 27447 | 6 | — | — | $2,456.53 | $11,893 | $20,698 |
| Knee revision arthroplasty single component | CPT | 27486 | 6 | — | — | $1,578.65 | $11,893 | $20,698 |
| Knee revision arthroplasty all components | CPT | 27487 | 6 | — | — | $2,356.43 | $11,893 | $20,698 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 4 | — | — | $695.82 | $3,093 | $5,174 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 6 | — | — | $568.05 | $7,836.95 | $18,111 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 6 | — | — | $908.9 | $4,345.77 | $12,418 |
| ACL reconstruction | CPT | 29888 | 6 | — | — | $1,112.81 | $7,836.95 | $18,111 |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 3 | — | — | $45,770 | $45,770 | $54,924 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 3 | — | — | $24,100 | $24,100 | $28,920 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 3 | — | — | $16,328 | $16,328 | $19,594 |
| CABG single arterial graft | CPT | 33533 | 3 | — | — | $3,087.84 | $8,279 | $15,004 |
| CABG 2 arterial grafts | CPT | 33534 | 3 | — | — | $3,472.29 | $8,279 | $15,004 |
| CABG 3 arterial grafts | CPT | 33535 | 3 | — | — | $3,856.12 | $8,279 | $15,004 |
| CABG 4+ arterial grafts | CPT | 33536 | 3 | — | — | $4,241.19 | $8,279 | $15,004 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 3 | — | — | $16,122 | $16,122 | $19,346 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 3 | — | — | $12,625 | $12,625 | $15,150 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 3 | — | — | $33,242 | $33,242 | $39,890 |
| Open appendectomy | CPT | 44950 | 6 | — | — | $660.8 | $4,321.1 | $12,418 |
| Laparoscopic appendectomy | CPT | 44970 | 6 | — | — | $450.78 | $6,451.05 | $18,111 |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 4 | — | — | $7,094 | $35,965 | $76,093 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 4 | — | — | $7,094 | $22,843 | $44,600 |
| Major joint replacement w MCC | MS-DRG | 469 | 4 | — | — | $7,094 | $18,867 | $35,056 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 4 | — | — | $7,094 | $13,314 | $21,729 |
| Laparoscopic cholecystectomy | CPT | 47562 | 6 | — | — | $768.89 | $6,963.23 | $18,111 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 6 | — | — | $884.96 | $6,963.23 | $18,111 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 3 | — | — | $28,652 | $28,652 | $34,382 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 3 | — | — | $19,941 | $19,941 | $23,930 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 3 | — | — | $15,734 | $15,734 | $18,881 |
| Open umbilical hernia repair | CPT | 49560 | 6 | — | — | $765.21 | $4,551.41 | $12,418 |
| Umbilical hernia repair age 5+ | CPT | 49585 | 6 | — | — | $487 | $4,551.41 | $12,418 |
| Lap inguinal hernia repair | CPT | 49650 | 6 | — | — | $436.66 | $6,330.21 | $18,111 |
| Lap incisional hernia repair | CPT | 49652 | 6 | — | — | $603.26 | $6,451.05 | $18,111 |
| Total abdominal hysterectomy | CPT | 58150 | 4 | — | — | $1,337.34 | $7,360 | $15,004 |
| Vaginal hysterectomy | CPT | 58260 | 6 | — | — | $1,337.34 | $5,515.98 | $12,418 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 6 | — | — | $1,383.3 | $7,485.85 | $18,111 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 6 | — | — | $709.15 | $10,754 | $18,111 |
| Lap salpingo-oophorectomy | CPT | 58661 | 6 | — | — | $806.59 | $6,330.21 | $18,111 |
| OR procedure for obesity w MCC | MS-DRG | 619 | 3 | — | — | $28,995 | $28,995 | $34,794 |
| OR procedure for obesity w CC | MS-DRG | 620 | 3 | — | — | $16,806 | $16,806 | $20,167 |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 3 | — | — | $15,262 | $15,262 | $18,314 |
| Complex cataract surgery | CPT | 66982 | 6 | — | — | $1,160.27 | $5,382.82 | $9,831 |
| Cataract surgery with lens implant | CPT | 66984 | 6 | — | — | $1,658.15 | $5,382.82 | $9,831 |
| Intravitreal injection | CPT | 67028 | 6 | — | — | $388.72 | $1,984.2 | $5,174 |
| Vitrectomy mechanical | CPT | 67042 | 6 | — | — | $1,082.35 | $5,105.89 | $15,004 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 3 | — | — | $10,911 | $10,911 | $13,093 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 3 | — | — | $17,115 | $17,115 | $20,537 |
| Left heart catheterization | CPT | 93452 | 7 | $8,921 | $6,244.7 | $877.29 | $7,248.4 | $15,004 |
| Coronary angiography with cath | CPT | 93455 | 7 | $23,044 | $16,131 | $1,057.41 | $7,650.52 | $18,435 |
| Coronary angiography with bypass cath | CPT | 93458 | 7 | $19,371 | $13,560 | $1,092.51 | $7,650.52 | $15,497 |