| behavioral |
| Psychoses | MS-DRG | 885 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Psychiatric diagnostic evaluation | CPT | 90791 | 15 | — | — | $65 | $162.89 | $362.88 |
| Psychiatric eval with medical services | CPT | 90792 | 15 | — | — | $65 | $162.89 | $362.88 |
| Psychotherapy 30 minutes | CPT | 90832 | 15 | — | — | $35 | $162.89 | $362.88 |
| Psychotherapy 45 minutes | CPT | 90834 | 15 | — | — | $63 | $162.89 | $362.88 |
| Psychotherapy 60 minutes | CPT | 90837 | 15 | — | — | $68 | $162.89 | $362.88 |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 15 | — | — | $161.28 | $162.89 | $362.88 |
| emergency |
| ED visit level 1 | CPT | 99281 | 16 | $1,023 | $409.2 | $88.38 | $91.03 | $1,169 |
| ED visit level 2 | CPT | 99282 | 16 | $1,537 | $614.8 | $158.96 | $163.73 | $2,631 |
| ED visit level 3 | CPT | 99283 | 16 | $3,235 | $1,294 | $277.94 | $286.28 | $4,445 |
| ED visit level 4 | CPT | 99284 | 16 | $4,443 | $1,777.2 | $427.43 | $440.25 | $5,555 |
| ED visit level 5 | CPT | 99285 | 16 | $4,424 | $1,769.6 | $615.42 | $633.88 | $5,994 |
| Critical care, first hour | CPT | 99291 | 16 | $11,416 | $4,566.4 | $845.8 | $871.17 | $7,096 |
| imaging |
| CT head without contrast | CPT | 70450 | 15 | $4,882 | $1,952.8 | $106.74 | $107.81 | $2,685.1 |
| CT head with contrast | CPT | 70460 | 15 | $5,260 | $2,104 | $178.69 | $180.48 | $2,893 |
| CT head with and without contrast | CPT | 70470 | 15 | $5,260 | $2,104 | $178.69 | $180.48 | $2,893 |
| CT neck with contrast | CPT | 70491 | 15 | $2,868 | $1,147.2 | $178.69 | $180.48 | $1,577.4 |
| MRI brain without contrast | CPT | 70551 | 15 | $1,999 | $799.6 | $242.63 | $245.06 | $1,645 |
| MRI brain with contrast | CPT | 70552 | 15 | $2,264 | $905.6 | $358.48 | $362.06 | $1,645 |
| MRI brain with and without contrast | CPT | 70553 | 15 | $3,314 | $1,325.6 | $358.48 | $362.06 | $1,822.7 |
| Chest X-ray single view | CPT | 71045 | 15 | $1,217 | $486.8 | $51.26 | $89.26 | $669.35 |
| Chest X-ray 2 views | CPT | 71046 | 15 | $1,400 | $560 | $67.8 | $89.26 | $770 |
| Chest X-ray 3 views | CPT | 71047 | 15 | $2,033 | $813.2 | $85.43 | $89.26 | $1,118.15 |
| CT chest without contrast | CPT | 71250 | 15 | $2,488 | $995.2 | $106.74 | $107.81 | $1,368.4 |
| CT chest with contrast | CPT | 71260 | 15 | $4,647 | $1,858.8 | $178.69 | $180.48 | $2,555.85 |
| CT chest with and without contrast | CPT | 71270 | 15 | $5,260 | $2,104 | $178.69 | $180.48 | $2,893 |
| MRI chest without contrast | CPT | 71550 | 15 | $2,726 | $1,090.4 | $242.63 | $245.06 | $1,499.3 |
| MRI chest with contrast | CPT | 71551 | 15 | $2,726 | $1,090.4 | $793.05 | $800.98 | $1,784.36 |
| MRI chest with and without contrast | CPT | 71552 | 15 | $2,726 | $1,090.4 | $358.48 | $362.06 | $1,499.3 |
| Lumbosacral spine X-ray | CPT | 72100 | 15 | $1,345 | $538 | $83.24 | $107.81 | $739.75 |
| CT cervical spine without contrast | CPT | 72125 | 15 | $5,260 | $2,104 | $106.74 | $107.81 | $2,893 |
| CT thoracic spine without contrast | CPT | 72128 | 15 | $3,825 | $1,530 | $106.74 | $107.81 | $2,103.75 |
| CT lumbar spine without contrast | CPT | 72131 | 15 | $4,609 | $1,843.6 | $106.74 | $107.81 | $2,534.95 |
| MRI cervical spine without contrast | CPT | 72141 | 15 | $3,012 | $1,204.8 | $242.63 | $245.06 | $1,656.6 |
| MRI thoracic spine without contrast | CPT | 72146 | 15 | $2,573 | $1,029.2 | $242.63 | $245.06 | $1,415.15 |
| MRI lumbar spine without contrast | CPT | 72148 | 15 | $3,216 | $1,286.4 | $242.63 | $245.06 | $1,768.8 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 15 | $2,742 | $1,096.8 | $358.48 | $362.06 | $1,508.1 |
| MRI cervical spine with and without contrast | CPT | 72156 | 15 | $3,186 | $1,274.4 | $358.48 | $362.06 | $1,752.3 |
| MRI lumbar spine with contrast | CPT | 72158 | 15 | $3,314 | $1,325.6 | $358.48 | $362.06 | $1,822.7 |
| CT pelvis without contrast | CPT | 72192 | 15 | $4,813 | $1,925.2 | $106.74 | $107.81 | $2,647.15 |
| CT pelvis with contrast | CPT | 72193 | 15 | $5,260 | $2,104 | $178.69 | $180.48 | $2,893 |
| Shoulder X-ray | CPT | 73030 | 15 | $5,594 | $2,237.6 | $73.32 | $89.26 | $3,076.7 |
| Humerus X-ray | CPT | 73060 | 15 | $5,029 | $2,011.6 | $71.09 | $89.26 | $2,765.95 |
| Hand X-ray 3 views | CPT | 73130 | 15 | $2,814 | $1,125.6 | $81.04 | $89.26 | $1,547.7 |
| MRI upper extremity joint without contrast | CPT | 73221 | 15 | $3,242 | $1,296.8 | $242.63 | $245.06 | $1,783.1 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 15 | $2,905 | $1,162 | $358.48 | $362.06 | $1,597.75 |
| Knee X-ray 1-2 views | CPT | 73560 | 15 | $3,463 | $1,385.2 | $77.72 | $89.26 | $1,904.65 |
| Ankle X-ray 3 views | CPT | 73610 | 15 | $2,988 | $1,195.2 | $81.04 | $89.26 | $1,643.4 |
| MRI lower extremity joint without contrast | CPT | 73721 | 15 | $3,314 | $1,325.6 | $242.63 | $245.06 | $1,822.7 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 15 | $3,314 | $1,325.6 | $358.48 | $362.06 | $1,822.7 |
| CT abdomen without contrast | CPT | 74150 | 15 | $3,532 | $1,412.8 | $106.74 | $107.81 | $1,942.6 |
| CT abdomen with contrast | CPT | 74160 | 15 | $5,010 | $2,004 | $178.69 | $180.48 | $2,755.5 |
| CT abdomen with and without contrast | CPT | 74170 | 15 | $5,227 | $2,090.8 | $178.69 | $180.48 | $2,874.85 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 15 | $5,260 | $2,104 | $242.63 | $245.06 | $2,893 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 15 | $5,260 | $2,104 | $358.48 | $362.06 | $2,893 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 15 | $5,260 | $2,104 | $358.48 | $362.06 | $2,893 |
| MRI abdomen without contrast | CPT | 74181 | 15 | $3,314 | $1,325.6 | $242.63 | $245.06 | $1,822.7 |
| MRI abdomen with and without contrast | CPT | 74183 | 15 | $3,314 | $1,325.6 | $358.48 | $362.06 | $1,822.7 |
| Abdominal ultrasound complete | CPT | 76700 | 15 | $6,381 | $2,552.4 | $106.74 | $107.81 | $3,509.55 |
| Abdominal ultrasound limited | CPT | 76705 | 15 | $5,388 | $2,155.2 | $106.74 | $107.81 | $2,963.4 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 15 | $1,520 | $608 | $106.74 | $107.81 | $836 |
| Obstetric ultrasound first trimester | CPT | 76801 | 15 | $1,701 | $680.4 | $106.74 | $107.81 | $935.55 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 15 | $3,159 | $1,263.6 | $106.74 | $107.81 | $1,737.45 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 15 | $3,348 | $1,339.2 | $242.63 | $245.06 | $1,841.4 |
| Transvaginal ultrasound | CPT | 76830 | 15 | $2,196 | $878.4 | $106.74 | $107.81 | $1,207.8 |
| Pelvic ultrasound complete | CPT | 76856 | 15 | $5,470 | $2,188 | $106.74 | $107.81 | $3,008.5 |
| Scrotal ultrasound | CPT | 76870 | 15 | $2,765 | $1,106 | $106.74 | $107.81 | $1,520.75 |
| Diagnostic mammography unilateral | CPT | 77065 | 15 | $1,633 | $653.2 | $80.31 | $81.11 | $898.15 |
| Diagnostic mammography bilateral | CPT | 77066 | 15 | $1,920 | $768 | $102.2 | $103.22 | $1,056 |
| Screening mammography bilateral | CPT | 77067 | 15 | $1,326 | $530.4 | $84.39 | $85.23 | $729.3 |
| EKG complete | CPT | 93000 | 1 | — | — | $4,515 | $4,515 | $4,515 |
| EKG tracing only | CPT | 93005 | 14 | — | — | $59.62 | $60.22 | $4,515 |
| EKG interpretation only | CPT | 93010 | 1 | — | — | $4,515 | $4,515 | $4,515 |
| Transthoracic echocardiogram complete | CPT | 93306 | 14 | $8,901 | $3,560.4 | $550.37 | $555.87 | $4,515 |
| Transthoracic echocardiogram | CPT | 93307 | 14 | $5,009 | $2,003.6 | $242.63 | $245.06 | $4,515 |
| Stress echocardiogram | CPT | 93350 | 14 | — | — | $550.37 | $555.87 | $4,515 |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 16 | — | — | $2,105 | $9,501.45 | $20,756 |
| COPD w MCC | MS-DRG | 190 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| COPD w CC | MS-DRG | 191 | 16 | — | — | $2,105 | $8,086.46 | $20,475 |
| COPD w/o CC/MCC | MS-DRG | 192 | 16 | — | — | $2,105 | $6,158.36 | $20,475 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 16 | — | — | $2,105 | $7,730.58 | $20,475 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 16 | — | — | $2,105 | $6,028.87 | $20,475 |
| AMI discharged alive w MCC | MS-DRG | 280 | 16 | — | — | $2,105 | $9,753.17 | $21,305 |
| AMI discharged alive w CC | MS-DRG | 281 | 16 | — | — | $2,105 | $8,816.44 | $20,475 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 16 | — | — | $2,105 | $6,936.31 | $20,475 |
| Heart failure & shock w MCC | MS-DRG | 291 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Heart failure & shock w CC | MS-DRG | 292 | 16 | — | — | $2,105 | $8,144.01 | $20,475 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 16 | — | — | $2,105 | $5,429.34 | $20,475 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 16 | — | — | $2,105 | $7,057.18 | $20,475 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 16 | — | — | $2,105 | $5,430.3 | $20,475 |
| GI hemorrhage w CC | MS-DRG | 378 | 16 | — | — | $2,105 | $9,366.31 | $20,475 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 16 | — | — | $2,105 | $6,047.1 | $20,475 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 16 | — | — | $2,105 | $7,478.3 | $20,475 |
| Fractures of femur w/o MCC | MS-DRG | 533 | 16 | — | — | $2,105 | $9,531.86 | $20,822 |
| Kidney/UTI w MCC | MS-DRG | 689 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 16 | — | — | $2,105 | $7,765.11 | $20,475 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 16 | — | — | $2,105 | $11,581 | $25,800 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Initial hospital care, low complexity | CPT | 99221 | 1 | — | — | $67.81 | $67.81 | $67.81 |
| Initial hospital care, moderate complexity | CPT | 99222 | 1 | — | — | $112.11 | $112.11 | $112.11 |
| Initial hospital care, high complexity | CPT | 99223 | 1 | — | — | $156.04 | $156.04 | $156.04 |
| Hospital discharge, <30 min | CPT | 99238 | 1 | — | — | $70.03 | $70.03 | $70.03 |
| Hospital discharge, >30 min | CPT | 99239 | 1 | — | — | $100 | $100 | $100 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 15 | $169.51 | $67.8 | $8.46 | $8.54 | $31.88 |
| General health panel | CPT | 80050 | 2 | $293.6 | $117.44 | $47.28 | $47.28 | $152.92 |
| Electrolyte panel | CPT | 80051 | 15 | $163.19 | $65.28 | $7.01 | $7.08 | $26.76 |
| Comprehensive metabolic panel | CPT | 80053 | 15 | $172.62 | $69.05 | $10.56 | $10.67 | $39.52 |
| Lipid panel | CPT | 80061 | 15 | $316.94 | $126.78 | $13.39 | $13.52 | $50.96 |
| Renal function panel | CPT | 80069 | 15 | $120.87 | $48.35 | $8.68 | $8.77 | $33.16 |
| Hepatic function panel | CPT | 80076 | 15 | $188.26 | $75.3 | $8.17 | $8.25 | $30.6 |
| Urinalysis non-automated | CPT | 81002 | 15 | $26.68 | $10.67 | $3.48 | $3.51 | $12.76 |
| Urinalysis automated | CPT | 81003 | 15 | $149.39 | $59.76 | $2.25 | $2.27 | $8.92 |
| Glucose quantitative | CPT | 82947 | 15 | $45 | $18 | $3.93 | $3.97 | $15.32 |
| Hemoglobin A1c | CPT | 83036 | 15 | $735.89 | $294.36 | $9.71 | $9.81 | $36.96 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 15 | $591.56 | $236.62 | $16.8 | $16.97 | $63.72 |
| Complete blood count with automated differential | CPT | 85025 | 15 | $227.24 | $90.9 | $7.77 | $7.85 | $29.32 |
| Complete blood count without differential | CPT | 85027 | 15 | $58.54 | $23.42 | $6.47 | $6.53 | $24.24 |
| Urine culture bacterial | CPT | 87086 | 15 | $240.12 | $96.05 | $8.07 | $8.15 | $30.6 |
| Urine culture identification | CPT | 87088 | 15 | — | — | $8.09 | $8.17 | $30.6 |
| Tissue exam by pathologist level IV | CPT | 88305 | 15 | $387 | $154.8 | $49.47 | $54.17 | $133.2 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 14 | — | — | $201.93 | $203.95 | $454.34 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 1 | — | — | $63.72 | $63.72 | $63.72 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 1 | — | — | $95.12 | $95.12 | $95.12 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 1 | — | — | $134.67 | $134.67 | $134.67 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 1 | — | — | $171.42 | $171.42 | $171.42 |
| Office visit, established patient, 5 min | CPT | 99211 | 1 | — | — | $20.73 | $20.73 | $20.73 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 1 | — | — | $37.61 | $37.61 | $37.61 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 1 | — | — | $51.26 | $51.26 | $51.26 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 1 | — | — | $80.56 | $80.56 | $80.56 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 1 | — | — | $117.66 | $117.66 | $117.66 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 14 | — | — | $941.1 | $950.51 | $11,698 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 14 | — | — | $941.1 | $950.51 | $11,698 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 14 | — | — | $915.16 | $924.31 | $11,698 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 14 | — | — | $915.16 | $924.31 | $11,698 |
| Colonoscopy diagnostic | CPT | 45378 | 14 | — | — | $915.16 | $924.31 | $11,698 |
| Colonoscopy with biopsy | CPT | 45380 | 1 | — | — | $5,849 | $8,773.5 | $11,698 |
| Colonoscopy with polyp removal | CPT | 45385 | 1 | — | — | $5,849 | $8,773.5 | $11,698 |
| surgery |
| Total hip replacement | CPT | 27130 | 2 | — | — | $22,388 | $25,632 | $28,875 |
| Total knee replacement | CPT | 27447 | 2 | — | — | $22,388 | $27,207 | $32,025 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 1 | — | — | $17,619 | $17,619 | $17,619 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 1 | — | — | $17,619 | $17,619 | $17,619 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 1 | — | — | $17,619 | $17,619 | $17,619 |
| ACL reconstruction | CPT | 29888 | 1 | — | — | $17,619 | $17,619 | $17,619 |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 16 | — | — | $2,105 | $27,133 | $61,050 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 16 | — | — | $2,105 | $14,227 | $31,839 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 16 | — | — | $2,105 | $10,232 | $22,352 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 16 | — | — | $2,105 | $10,285 | $22,468 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 16 | — | — | $2,105 | $20,112 | $45,253 |
| Open appendectomy | CPT | 44950 | 1 | — | — | $5,849 | $8,773.5 | $11,698 |
| Major joint replacement w MCC | MS-DRG | 469 | 16 | — | — | $2,105 | $17,905 | $44,626 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 16 | — | — | $2,105 | $11,540 | $44,626 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 16 | — | — | $2,105 | $17,191 | $38,681 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 16 | — | — | $2,105 | $12,488 | $32,820 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 16 | — | — | $2,105 | $9,916.73 | $32,820 |
| Lap inguinal hernia repair | CPT | 49650 | 1 | — | — | $28,358 | $28,358 | $28,358 |
| OR procedure for obesity w MCC | MS-DRG | 619 | 16 | — | — | $2,105 | $17,045 | $38,350 |
| OR procedure for obesity w CC | MS-DRG | 620 | 16 | — | — | $2,105 | $9,730.07 | $30,965 |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 16 | — | — | $2,105 | $9,470 | $30,965 |
| Intravitreal injection | CPT | 67028 | 14 | — | — | $332.94 | $336.27 | $749.12 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 16 | — | — | $2,105 | $9,470 | $20,475 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 16 | — | — | $2,105 | $12,217 | $27,216 |
| PCI single major coronary artery | CPT | 92920 | 3 | $21,790 | $8,716 | $8,202 | $21,286 | $31,515 |
| PCI with drug-eluting stent | CPT | 92928 | 3 | $31,781 | $12,712 | $18,913 | $21,286 | $31,515 |
| PCI bypass graft | CPT | 92937 | 3 | $30,268 | $12,107 | $18,913 | $21,286 | $31,515 |
| Left heart catheterization | CPT | 93452 | 1 | — | — | $12,222 | $12,222 | $12,222 |
| Coronary angiography with cath | CPT | 93455 | 1 | — | — | $12,222 | $12,222 | $12,222 |
| Coronary angiography with bypass cath | CPT | 93458 | 1 | — | — | $12,222 | $12,222 | $12,222 |