| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $450 | $450 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $791 | $791 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $1,300 | $1,300 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $2,253 | $2,253 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $2,463 | $2,463 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $4,771 | $4,771 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $3,590 | $3,590 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $3,694 | $3,694 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $4,627 | $4,627 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $3,460 | $3,460 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $4,218 | $4,218 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $5,221 | $5,221 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $8,053 | $8,053 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $393 | $393 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $529 | $529 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $658 | $658 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $4,443 | $4,443 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $4,585 | $4,585 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $5,221 | $5,221 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $6,508 | $6,508 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $5,502 | $5,502 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $8,533 | $8,533 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $876 | $876 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $4,546 | $4,546 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $4,560 | $4,560 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $4,529 | $4,529 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $5,686 | $5,686 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $5,849 | $5,849 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $6,550 | $6,550 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $8,084 | $8,084 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $9,164 | $9,164 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $8,116 | $8,116 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $2,971 | $2,971 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $4,844 | $4,844 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $773 | $773 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $751 | $751 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $802 | $802 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $6,424 | $6,424 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $7,799 | $7,799 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $738 | $738 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $829 | $829 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $6,424 | $6,424 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $8,190 | $8,190 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $3,948 | $3,948 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $4,869 | $4,869 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $5,422 | $5,422 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $6,857 | $6,857 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $7,838 | $7,838 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $8,137 | $8,137 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $4,404 | $4,404 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $7,708 | $7,708 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $2,055 | $2,055 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,569 | $1,569 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,905 | $1,905 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $1,320 | $1,320 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,275 | $1,275 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,479 | $1,479 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $1,422 | $1,422 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $1,784 | $1,784 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,468 | $1,468 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $718 | $718 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $887 | $887 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $604 | $604 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $357 | $357 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $4,507 | $4,507 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $3,246 | $3,246 | — | — | — |
| inpatient |
| Intracranial hemorrhage/CVA w MCC | MS-DRG | 064 | 0 | — | — | — | — | — |
| Intracranial hemorrhage/CVA w CC | MS-DRG | 065 | 0 | — | — | — | — | — |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG | 066 | 0 | — | — | — | — | — |
| 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 | $147 | $147 | — | — | — |
| General health panel | CPT | 80050 | 0 | $773 | $773 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $86 | $86 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $265 | $265 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $327 | $327 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $123 | $123 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $308 | $308 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $54 | $54 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $99 | $99 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $104 | $104 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $254 | $254 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $337 | $337 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $163 | $163 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $151 | $151 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $135 | $135 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $135 | $135 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $550 | $550 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $942 | $942 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $6,449 | $6,449 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $336 | $336 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $359 | $359 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $616 | $616 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $1,155 | $1,155 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $249 | $249 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $288 | $288 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $311 | $311 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $458 | $458 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $1,088 | $1,088 | — | — | — |
| preventive |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $1,900 | $1,900 | — | — | — |
| surgery |
| 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 | — | — | — | — | — |
| 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 | — | — | — | — | — |
| 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 | — | — | — | — | — |
| 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 | $11,776 | $11,776 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $17,235 | $17,235 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $23,146 | $23,146 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $11,289 | $11,289 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $9,005 | $9,005 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $9,208 | $9,208 | — | — | — |
