| behavioral |
| Psychoses | MS-DRG | 885 | 7 | — | — | $11,197 | $11,197 | $11,197 |
| emergency |
| ED visit level 1 | CPT | 99281 | 16 | $827 | $578.9 | $21.77 | $530.57 | $5,164 |
| ED visit level 2 | CPT | 99282 | 16 | $1,532 | $1,072.4 | $34.97 | $978.01 | $8,816 |
| ED visit level 3 | CPT | 99283 | 16 | $2,817 | $1,971.9 | $63.97 | $1,866.11 | $11,753 |
| ED visit level 4 | CPT | 99284 | 16 | $4,411 | $3,087.7 | $98.04 | $3,065.65 | $18,887 |
| ED visit level 5 | CPT | 99285 | 16 | $7,350 | $5,145 | $155.03 | $5,108.25 | $26,218 |
| Critical care, first hour | CPT | 99291 | 16 | $10,788 | $7,551.6 | $318 | $7,443.72 | $28,467 |
| imaging |
| CT head without contrast | CPT | 70450 | 12 | $6,495 | $4,546.5 | $132.18 | $316.23 | $6,495 |
| CT head with contrast | CPT | 70460 | 12 | $8,899 | $6,229.3 | $209.04 | $422.26 | $8,899 |
| CT head with and without contrast | CPT | 70470 | 12 | $10,654 | $7,457.8 | $216.88 | $499.4 | $10,654 |
| CT neck with contrast | CPT | 70491 | 12 | $9,357 | $6,549.9 | $216.88 | $531.06 | $9,357 |
| MRI brain without contrast | CPT | 70551 | 12 | $13,139 | $9,197.3 | $278.36 | $5,118 | $13,139 |
| MRI brain with contrast | CPT | 70552 | 12 | $13,816 | $9,671.2 | $396.44 | $1,366.21 | $13,816 |
| MRI brain with and without contrast | CPT | 70553 | 12 | $15,881 | $11,117 | $447.1 | $1,437.71 | $15,881 |
| Chest X-ray single view | CPT | 71045 | 12 | $1,071 | $749.7 | $17.67 | $98.21 | $1,071 |
| Chest X-ray 2 views | CPT | 71046 | 12 | $1,390 | $973 | $27.48 | $98.47 | $1,390 |
| Chest X-ray 3 views | CPT | 71047 | 12 | $2,153 | $1,507.1 | $35.27 | $98.47 | $2,153 |
| CT chest without contrast | CPT | 71250 | 12 | $3,773 | $2,641.1 | $132.18 | $377.98 | $3,773 |
| CT chest with contrast | CPT | 71260 | 12 | $7,396 | $5,177.2 | $216.88 | $480.8 | $7,396 |
| CT chest with and without contrast | CPT | 71270 | 12 | $8,357 | $5,849.9 | $216.88 | $571.36 | $8,357 |
| MRI chest without contrast | CPT | 71550 | 12 | $3,856 | $2,699.2 | $278.36 | $1,486.14 | $5,118 |
| MRI chest with contrast | CPT | 71551 | 12 | $3,235 | $2,264.5 | $395.33 | $1,401.29 | $5,118 |
| MRI chest with and without contrast | CPT | 71552 | 12 | $3,966 | $2,776.2 | $447.1 | $1,471.93 | $5,118 |
| Lumbosacral spine X-ray | CPT | 72100 | 12 | $1,679 | $1,175.3 | $43.45 | $133.88 | $1,679 |
| CT cervical spine without contrast | CPT | 72125 | 12 | $8,907 | $6,234.9 | $132.18 | $373.86 | $8,907 |
| CT thoracic spine without contrast | CPT | 72128 | 12 | $8,907 | $6,234.9 | $132.18 | $373.86 | $8,907 |
| CT lumbar spine without contrast | CPT | 72131 | 12 | $8,907 | $6,234.9 | $132.18 | $373.86 | $8,907 |
| MRI cervical spine without contrast | CPT | 72141 | 12 | $10,091 | $7,063.7 | $277.53 | $2,768 | $10,091 |
| MRI thoracic spine without contrast | CPT | 72146 | 12 | $8,031 | $5,621.7 | $277.53 | $3,109.14 | $8,031 |
| MRI lumbar spine without contrast | CPT | 72148 | 12 | $11,102 | $7,771.4 | $277.97 | $2,768.28 | $11,102 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 12 | $14,882 | $10,417 | $399.67 | $3,845.7 | $14,882 |
| MRI cervical spine with and without contrast | CPT | 72156 | 12 | $16,851 | $11,796 | $447.1 | $3,938.24 | $16,851 |
| MRI lumbar spine with contrast | CPT | 72158 | 12 | $18,541 | $12,979 | $447.1 | $4,429.37 | $18,541 |
| CT pelvis without contrast | CPT | 72192 | 12 | $6,674 | $4,671.8 | $132.18 | $2,230.37 | $6,674 |
| CT pelvis with contrast | CPT | 72193 | 12 | $13,150 | $9,205 | $216.88 | $592.39 | $13,150 |
| Shoulder X-ray | CPT | 73030 | 12 | $1,247 | $872.9 | $37.09 | $267.55 | $1,247 |
| Humerus X-ray | CPT | 73060 | 12 | $1,169 | $818.3 | $29.81 | $254 | $1,169 |
| Hand X-ray 3 views | CPT | 73130 | 12 | $1,210 | $847 | $36.06 | $232.69 | $1,210 |
| MRI upper extremity joint without contrast | CPT | 73221 | 12 | $6,911 | $4,837.7 | $278.36 | $3,109.14 | $6,911 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 12 | $11,542 | $8,079.4 | $408.36 | $1,381 | $11,542 |
| Knee X-ray 1-2 views | CPT | 73560 | 12 | $988 | $691.6 | $27.28 | $250.08 | $988 |
| Ankle X-ray 3 views | CPT | 73610 | 12 | $1,172 | $820.4 | $36.06 | $254.14 | $1,172 |
| MRI lower extremity joint without contrast | CPT | 73721 | 12 | $5,461 | $3,822.7 | $278.36 | $2,913.18 | $5,461 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 12 | $10,337 | $7,235.9 | $407.06 | $5,828.75 | $10,337 |
| CT abdomen without contrast | CPT | 74150 | 12 | $3,158 | $2,210.6 | $132.18 | $388.18 | $3,158 |
| CT abdomen with contrast | CPT | 74160 | 12 | $4,868 | $3,407.6 | $216.88 | $604.89 | $4,868 |
| CT abdomen with and without contrast | CPT | 74170 | 12 | $5,658 | $3,960.6 | $216.88 | $688.56 | $5,658 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 12 | $4,409 | $3,086.3 | $178.43 | $360.43 | $4,409 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 12 | $6,326 | $4,428.2 | $281.8 | $569.24 | $6,326 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 12 | $7,698 | $5,388.6 | $319.24 | $644.86 | $7,698 |
| MRI abdomen without contrast | CPT | 74181 | 12 | $12,512 | $8,758.4 | $278.36 | $5,118 | $12,512 |
| MRI abdomen with and without contrast | CPT | 74183 | 12 | $20,896 | $14,627 | $351.25 | $671.42 | $20,896 |
| Abdominal ultrasound complete | CPT | 76700 | 12 | $3,156 | $2,209.2 | $119.34 | $241.07 | $3,156 |
| Abdominal ultrasound limited | CPT | 76705 | 12 | $2,427 | $1,698.9 | $87.13 | $532.77 | $2,427 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 12 | $2,463 | $1,724.1 | $115.78 | $233.88 | $2,463 |
| Obstetric ultrasound first trimester | CPT | 76801 | 12 | $911 | $637.7 | $78.42 | $158.41 | $911 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 12 | $1,058 | $740.6 | $132.18 | $699.34 | $1,058 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 12 | $348 | $243.6 | $159.03 | $279.37 | $348 |
| Transvaginal ultrasound | CPT | 76830 | 12 | $2,028 | $1,419.6 | $97.04 | $196.02 | $2,028 |
| Pelvic ultrasound complete | CPT | 76856 | 12 | $2,551 | $1,785.7 | $97.04 | $196.02 | $2,551 |
| Scrotal ultrasound | CPT | 76870 | 12 | $3,071 | $2,149.7 | $85.75 | $173.22 | $3,071 |
| Diagnostic mammography unilateral | CPT | 77065 | 9 | $792 | $554.4 | $101 | $510.45 | $792 |
| Diagnostic mammography bilateral | CPT | 77066 | 9 | $896 | $627.2 | $128.8 | $727.07 | $896 |
| Screening mammography bilateral | CPT | 77067 | 9 | $896 | $627.2 | $106.79 | $667.52 | $896 |
| EKG tracing only | CPT | 93005 | 12 | $610 | $427 | $26.34 | $326.4 | $610 |
| Transthoracic echocardiogram complete | CPT | 93306 | 12 | $6,143 | $4,300.1 | $239.76 | $2,986.39 | $6,143 |
| Transthoracic echocardiogram | CPT | 93307 | 12 | $1,692 | $1,184.4 | $215.3 | $1,073.13 | $1,692 |
| Stress echocardiogram | CPT | 93350 | 12 | $4,173 | $2,921.1 | $137.87 | $1,273.14 | $4,173 |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 7 | — | — | $16,523 | $16,523 | $16,523 |
| COPD w MCC | MS-DRG | 190 | 7 | — | — | $10,199 | $10,199 | $10,199 |
| COPD w CC | MS-DRG | 191 | 7 | — | — | $8,095.48 | $8,095.48 | $8,095.48 |
| COPD w/o CC/MCC | MS-DRG | 192 | 7 | — | — | $6,447.15 | $6,447.15 | $6,447.15 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 7 | — | — | $7,917.28 | $7,917.28 | $7,917.28 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 7 | — | — | $6,186.84 | $6,186.84 | $6,186.84 |
| AMI discharged alive w MCC | MS-DRG | 280 | 7 | — | — | $14,408 | $14,408 | $14,408 |
| AMI discharged alive w CC | MS-DRG | 281 | 7 | — | — | $8,499.92 | $8,499.92 | $8,499.92 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 7 | — | — | $6,713.57 | $6,713.57 | $6,713.57 |
| Heart failure & shock w MCC | MS-DRG | 291 | 7 | — | — | $11,450 | $11,450 | $11,450 |
| Heart failure & shock w CC | MS-DRG | 292 | 7 | — | — | $7,913.79 | $7,913.79 | $7,913.79 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 7 | — | — | $5,523.83 | $5,523.83 | $5,523.83 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 7 | — | — | $10,861 | $10,861 | $10,861 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 7 | — | — | $6,926.71 | $6,926.71 | $6,926.71 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 7 | — | — | $5,255.66 | $5,255.66 | $5,255.66 |
| GI hemorrhage w CC | MS-DRG | 378 | 7 | — | — | $9,049.37 | $9,049.37 | $9,049.37 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 7 | — | — | $5,937.01 | $5,937.01 | $5,937.01 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 7 | — | — | $7,060.36 | $7,060.36 | $7,060.36 |
| Fractures of femur w/o MCC | MS-DRG | 533 | 7 | — | — | $12,742 | $12,742 | $12,742 |
| Kidney/UTI w MCC | MS-DRG | 689 | 7 | — | — | $10,104 | $10,104 | $10,104 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 7 | — | — | $7,306.69 | $7,306.69 | $7,306.69 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 7 | — | — | $16,725 | $16,725 | $16,725 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 7 | — | — | $9,335.88 | $9,335.88 | $9,335.88 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 10 | $755 | $528.5 | $8.46 | $133.53 | $705.93 |
| Electrolyte panel | CPT | 80051 | 10 | $698 | $488.6 | $7.01 | $86.19 | $652.63 |
| Comprehensive metabolic panel | CPT | 80053 | 10 | $941 | $658.7 | $10.56 | $177.24 | $879.84 |
| Lipid panel | CPT | 80061 | 10 | $630 | $441 | $3.18 | $15.36 | $589.05 |
| Renal function panel | CPT | 80069 | 10 | $932 | $652.4 | $8.68 | $142.88 | $871.42 |
| Hepatic function panel | CPT | 80076 | 10 | $769 | $538.3 | $8.17 | $123.55 | $719.02 |
| Urinalysis non-automated | CPT | 81002 | 10 | $88 | $61.6 | $3.08 | $34.03 | $82.28 |
| Urinalysis automated | CPT | 81003 | 10 | $120 | $84 | $2.25 | $26.35 | $112.2 |
| Glucose quantitative | CPT | 82947 | 10 | $472 | $330.4 | $3.93 | $51.04 | $441.32 |
| Hemoglobin A1c | CPT | 83036 | 10 | $206 | $144.2 | $1.5 | $22.48 | $199.14 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 10 | $423 | $296.1 | $6 | $22.65 | $395.51 |
| Complete blood count with automated differential | CPT | 85025 | 10 | $437 | $305.9 | $7.77 | $86.63 | $408.6 |
| Complete blood count without differential | CPT | 85027 | 10 | $466 | $326.2 | $6.47 | $60.69 | $435.71 |
| Urine culture bacterial | CPT | 87086 | 10 | $348 | $243.6 | $8.07 | $104.08 | $325.38 |
| Urine culture identification | CPT | 87088 | 10 | $124 | $86.8 | $6.81 | $44.6 | $124 |
| Tissue exam by pathologist level IV | CPT | 88305 | 12 | $268 | $187.6 | $58.8 | $118.78 | $268 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 16 | $905 | $633.5 | $16.89 | $580.92 | $8,966 |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 4 | — | — | $1,748.8 | $4,818.19 | $17,208 |
| Vaginal delivery only | CPT | 59409 | 8 | — | — | $780.72 | $3,189.78 | $17,208 |
| Vaginal delivery with postpartum | CPT | 59410 | 3 | — | — | $4,788 | $7,630.68 | $17,208 |
| Routine obstetric care with C-section | CPT | 59510 | 4 | — | — | $1,748.9 | $5,506.5 | $17,208 |
| C-section delivery only | CPT | 59514 | 4 | — | — | $781.35 | $5,506.5 | $17,208 |
| C-section with postpartum | CPT | 59515 | 3 | — | — | $5,506.5 | $9,461 | $17,208 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 7 | $448 | $313.6 | $49.2 | $166.86 | $448 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 7 | $301 | $210.7 | $82.05 | $189.1 | $281.44 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 7 | $2,368 | $1,657.6 | $98.83 | $240 | $2,368 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 7 | $434 | $303.8 | $118.62 | $244.01 | $405.79 |
| Office visit, established patient, 5 min | CPT | 99211 | 7 | $231 | $161.7 | $17.21 | $158.7 | $226 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 7 | $245 | $171.5 | $16.37 | $115.33 | $229.08 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 7 | $295 | $206.5 | $34.43 | $139.51 | $275.83 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 7 | $2,368 | $1,657.6 | $53.79 | $174 | $2,368 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 7 | $425 | $297.5 | $82.05 | $186.01 | $397.38 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 9 | — | — | $357.41 | $982.43 | $12,552 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 9 | — | — | $357.41 | $982.43 | $12,552 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 9 | — | — | $87.92 | $963.51 | $11,205 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 9 | — | — | $116.04 | $963.51 | $11,205 |
| Colonoscopy diagnostic | CPT | 45378 | 9 | — | — | $347.39 | $966.09 | $12,552 |
| Colonoscopy with biopsy | CPT | 45380 | 9 | — | — | $456.69 | $1,259.03 | $12,552 |
| Colonoscopy with polyp removal | CPT | 45385 | 9 | — | — | $456.69 | $1,262.4 | $12,552 |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 7 | — | — | $1,390.8 | $14,971 | $35,860 |
| PCI w drug-eluting stent w MCC | MS-DRG | 246 | 7 | — | — | $27,662 | $27,662 | $27,662 |
| PCI w drug-eluting stent w/o MCC | MS-DRG | 247 | 7 | — | — | $17,607 | $17,607 | $17,607 |
| Hip hemiarthroplasty | CPT | 27125 | 6 | — | — | $1,674.72 | $9,933 | $31,378 |
| Total hip replacement | CPT | 27130 | 8 | — | — | $2,392.44 | $14,971 | $35,860 |
| Total knee replacement | CPT | 27447 | 9 | — | — | $2,392.44 | $14,971 | $35,860 |
| Knee revision arthroplasty single component | CPT | 27486 | 4 | — | — | $1,537.46 | $11,966 | $35,860 |
| Knee revision arthroplasty all components | CPT | 27487 | 6 | — | — | $2,294.96 | $9,575 | $35,860 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 6 | — | — | $605.06 | $7,310 | $19,101 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 9 | — | — | $553.24 | $7,604.94 | $31,378 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 9 | — | — | $790.35 | $3,438.4 | $21,517 |
| ACL reconstruction | CPT | 29888 | 9 | — | — | $1,083.78 | $7,604.94 | $31,378 |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 7 | — | — | $43,053 | $43,053 | $43,053 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 7 | — | — | $22,640 | $22,640 | $22,640 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 7 | — | — | $15,313 | $15,313 | $15,313 |
| CABG single arterial graft | CPT | 33533 | 5 | — | — | $3,007.29 | $13,565 | $25,999 |
| CABG 2 arterial grafts | CPT | 33534 | 5 | — | — | $3,381.71 | $14,284 | $33,793 |
| CABG 3 arterial grafts | CPT | 33535 | 5 | — | — | $3,755.53 | $14,284 | $33,793 |
| CABG 4+ arterial grafts | CPT | 33536 | 5 | — | — | $4,130.55 | $14,284 | $33,793 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 7 | — | — | $15,125 | $15,125 | $15,125 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 7 | — | — | $11,860 | $11,860 | $11,860 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 7 | — | — | $31,088 | $31,088 | $31,088 |
| Open appendectomy | CPT | 44950 | 8 | — | — | $643.56 | $3,862.89 | $21,517 |
| Laparoscopic appendectomy | CPT | 44970 | 8 | — | — | $439.02 | $6,151.67 | $31,378 |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 7 | — | — | $59,190 | $59,190 | $59,190 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 7 | — | — | $34,706 | $34,706 | $34,706 |
| Major joint replacement w MCC | MS-DRG | 469 | 7 | — | — | $27,327 | $27,327 | $27,327 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 7 | — | — | $16,970 | $16,970 | $16,970 |
| Laparoscopic cholecystectomy | CPT | 47562 | 9 | — | — | $748.83 | $6,143.45 | $33,793 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 9 | — | — | $861.87 | $6,143.45 | $33,793 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 7 | — | — | $26,802 | $26,802 | $26,802 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 7 | — | — | $18,681 | $18,681 | $18,681 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 7 | — | — | $14,747 | $14,747 | $14,747 |
| Open umbilical hernia repair | CPT | 49560 | 9 | — | — | $745.25 | $3,862.89 | $21,517 |
| Umbilical hernia repair age 5+ | CPT | 49585 | 9 | — | — | $474.3 | $3,862.89 | $21,517 |
| Lap inguinal hernia repair | CPT | 49650 | 9 | — | — | $379.7 | $6,143.45 | $31,378 |
| Lap incisional hernia repair | CPT | 49652 | 9 | — | — | $524.57 | $6,143.45 | $31,378 |
| Total abdominal hysterectomy | CPT | 58150 | 6 | — | — | $1,162.9 | $11,226 | $24,272 |
| Vaginal hysterectomy | CPT | 58260 | 9 | — | — | $1,162.9 | $5,353.84 | $24,272 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 9 | — | — | $838.74 | $6,143.45 | $31,378 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 9 | — | — | $616.65 | $10,814 | $31,378 |
| Lap salpingo-oophorectomy | CPT | 58661 | 9 | — | — | $701.38 | $6,143.45 | $31,378 |
| OR procedure for obesity w MCC | MS-DRG | 619 | 7 | — | — | $27,116 | $27,116 | $27,116 |
| OR procedure for obesity w CC | MS-DRG | 620 | 7 | — | — | $15,769 | $15,769 | $15,769 |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 7 | — | — | $14,322 | $14,322 | $14,322 |
| Complex cataract surgery | CPT | 66982 | 9 | — | — | $911.47 | $2,528.07 | $22,801 |
| Cataract surgery with lens implant | CPT | 66984 | 9 | — | — | $911.47 | $2,528.07 | $22,801 |
| Intravitreal injection | CPT | 67028 | 9 | — | — | $42.56 | $658.63 | $8,966 |
| Vitrectomy mechanical | CPT | 67042 | 9 | — | — | $1,054.11 | $4,754.79 | $25,999 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 7 | — | — | $10,266 | $10,266 | $10,266 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 7 | — | — | $16,054 | $16,054 | $16,054 |
| PCI single major coronary artery | CPT | 92920 | 13 | $18,039 | $12,627 | $435.12 | $9,103.15 | $33,793 |
| PCI with drug-eluting stent | CPT | 92928 | 13 | $25,951 | $18,166 | $483.05 | $12,464 | $33,793 |
| PCI bypass graft | CPT | 92937 | 12 | $25,951 | $18,166 | $482.46 | $12,699 | $33,793 |
| Left heart catheterization | CPT | 93452 | 13 | $1,087 | $760.9 | $543.5 | $3,520.71 | $25,999 |
| Coronary angiography with cath | CPT | 93455 | 13 | $15,038 | $10,527 | $1,029.83 | $8,729.56 | $33,793 |
| Coronary angiography with bypass cath | CPT | 93458 | 13 | $23,290 | $16,303 | $1,064.01 | $12,200 | $33,793 |