| behavioral |
| Psychoses | MS-DRG | 885 | 9 | — | — | $1,055.6 | $12,064 | $20,267 |
| emergency |
| ED visit level 1 | CPT | 99281 | 10 | $111 | $66.6 | $17.76 | $80.87 | $103.23 |
| ED visit level 2 | CPT | 99282 | 10 | $254 | $152.4 | $40.64 | $145.44 | $236.22 |
| ED visit level 3 | CPT | 99283 | 10 | $488 | $292.8 | $78.08 | $254.3 | $453.84 |
| ED visit level 4 | CPT | 99284 | 10 | $3,079 | $1,847.4 | $391.07 | $492.64 | $2,863.47 |
| ED visit level 5 | CPT | 99285 | 10 | $5,248 | $3,148.8 | $313.28 | $997.12 | $4,880.64 |
| imaging |
| CT head without contrast | CPT | 70450 | 10 | $2,821 | $1,692.6 | $97.66 | $451.36 | $2,623.53 |
| CT head with contrast | CPT | 70460 | 10 | $3,088 | $1,852.8 | $163.49 | $494.08 | $2,871.84 |
| CT head with and without contrast | CPT | 70470 | 10 | $4,386 | $2,631.6 | $163.49 | $701.76 | $4,078.98 |
| CT neck with contrast | CPT | 70491 | 10 | $3,936 | $2,361.6 | $163.49 | $629.76 | $3,660.48 |
| MRI brain without contrast | CPT | 70551 | 10 | $6,272 | $3,763.2 | $222 | $1,003.52 | $5,832.96 |
| MRI brain with contrast | CPT | 70552 | 10 | $7,065 | $4,239 | $327.99 | $1,130.4 | $6,570.45 |
| MRI brain with and without contrast | CPT | 70553 | 10 | $9,015 | $5,409 | $327.99 | $1,442.4 | $8,383.95 |
| Chest X-ray single view | CPT | 71045 | 10 | $431 | $258.6 | $68.96 | $80.87 | $400.83 |
| Chest X-ray 2 views | CPT | 71046 | 10 | $504 | $302.4 | $80.64 | $80.87 | $468.72 |
| Chest X-ray 3 views | CPT | 71047 | 10 | $504 | $302.4 | $80.64 | $80.87 | $468.72 |
| CT chest without contrast | CPT | 71250 | 10 | $3,467 | $2,080.2 | $97.66 | $554.72 | $3,224.31 |
| CT chest with contrast | CPT | 71260 | 10 | $4,746 | $2,847.6 | $163.49 | $759.36 | $4,413.78 |
| CT chest with and without contrast | CPT | 71270 | 10 | $5,674 | $3,404.4 | $163.49 | $907.84 | $5,276.82 |
| MRI chest without contrast | CPT | 71550 | 10 | $6,272 | $3,763.2 | $222 | $1,003.52 | $5,832.96 |
| Lumbosacral spine X-ray | CPT | 72100 | 10 | $583 | $349.8 | $93.28 | $97.66 | $542.19 |
| CT cervical spine without contrast | CPT | 72125 | 10 | $4,203 | $2,521.8 | $97.66 | $672.48 | $3,908.79 |
| CT thoracic spine without contrast | CPT | 72128 | 10 | $4,278 | $2,566.8 | $97.66 | $684.48 | $3,978.54 |
| CT lumbar spine without contrast | CPT | 72131 | 10 | $3,982 | $2,389.2 | $97.66 | $637.12 | $3,703.26 |
| MRI cervical spine without contrast | CPT | 72141 | 10 | $5,862 | $3,517.2 | $222 | $937.92 | $5,451.66 |
| MRI thoracic spine without contrast | CPT | 72146 | 10 | $6,272 | $3,763.2 | $222 | $1,003.52 | $5,832.96 |
| MRI lumbar spine without contrast | CPT | 72148 | 10 | $5,849 | $3,509.4 | $222 | $935.84 | $5,439.57 |
| MRI cervical spine with and without contrast | CPT | 72156 | 10 | $9,528 | $5,716.8 | $327.99 | $1,524.48 | $8,861.04 |
| MRI lumbar spine with contrast | CPT | 72158 | 10 | $7,193 | $4,315.8 | $327.99 | $1,150.88 | $6,689.49 |
| CT pelvis without contrast | CPT | 72192 | 10 | $3,329 | $1,997.4 | $97.66 | $532.64 | $3,095.97 |
| CT pelvis with contrast | CPT | 72193 | 10 | $4,613 | $2,767.8 | $163.49 | $738.08 | $4,290.09 |
| Shoulder X-ray | CPT | 73030 | 10 | $1,008 | $604.8 | $80.64 | $164.51 | $937.44 |
| Humerus X-ray | CPT | 73060 | 10 | $1,008 | $604.8 | $80.64 | $164.51 | $937.44 |
| Hand X-ray 3 views | CPT | 73130 | 10 | $1,010 | $606 | $80.8 | $164.83 | $939.3 |
| MRI upper extremity joint without contrast | CPT | 73221 | 10 | $5,862 | $3,517.2 | $222 | $937.92 | $5,451.66 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 10 | $6,272 | $3,763.2 | $327.99 | $1,003.52 | $5,832.96 |
| Knee X-ray 1-2 views | CPT | 73560 | 10 | $940 | $564 | $75.04 | $153.41 | $874.2 |
| Ankle X-ray 3 views | CPT | 73610 | 10 | $1,070 | $642 | $80.87 | $174.62 | $995.1 |
| MRI lower extremity joint without contrast | CPT | 73721 | 10 | $5,862 | $3,517.2 | $222 | $937.92 | $5,451.66 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 10 | $6,272 | $3,763.2 | $327.99 | $1,003.52 | $5,832.96 |
| CT abdomen without contrast | CPT | 74150 | 10 | $3,003 | $1,801.8 | $97.66 | $480.48 | $2,792.79 |
| CT abdomen with contrast | CPT | 74160 | 10 | $3,701 | $2,220.6 | $163.49 | $592.16 | $3,441.93 |
| CT abdomen with and without contrast | CPT | 74170 | 10 | $4,418 | $2,650.8 | $163.49 | $706.88 | $4,108.74 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 10 | $6,328 | $3,796.8 | $222 | $1,012.48 | $5,885.04 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 10 | $8,312 | $4,987.2 | $327.99 | $1,329.92 | $7,730.16 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 10 | $10,155 | $6,093 | $327.99 | $1,624.8 | $9,444.15 |
| MRI abdomen without contrast | CPT | 74181 | 10 | $4,883 | $2,929.8 | $222 | $781.28 | $4,541.19 |
| MRI abdomen with and without contrast | CPT | 74183 | 10 | $5,225 | $3,135 | $327.99 | $836 | $4,859.25 |
| Abdominal ultrasound complete | CPT | 76700 | 10 | $1,687 | $1,012.2 | $97.66 | $269.92 | $1,568.91 |
| Abdominal ultrasound limited | CPT | 76705 | 10 | $1,027 | $616.2 | $97.66 | $164.32 | $955.11 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 10 | $897 | $538.2 | $97.66 | $143.52 | $834.21 |
| Obstetric ultrasound first trimester | CPT | 76801 | 10 | $1,465 | $879 | $97.66 | $234.4 | $1,362.45 |
| Transvaginal ultrasound | CPT | 76830 | 10 | $1,604 | $962.4 | $97.66 | $256.64 | $1,491.72 |
| Pelvic ultrasound complete | CPT | 76856 | 10 | $1,408 | $844.8 | $97.66 | $225.28 | $1,309.44 |
| Scrotal ultrasound | CPT | 76870 | 10 | $1,604 | $962.4 | $97.66 | $256.64 | $1,491.72 |
| Diagnostic mammography unilateral | CPT | 77065 | 10 | $482 | $289.2 | $76.62 | $77.12 | $448.26 |
| Diagnostic mammography bilateral | CPT | 77066 | 10 | $964 | $578.4 | $98.3 | $154.24 | $896.52 |
| Screening mammography bilateral | CPT | 77067 | 10 | $398 | $238.8 | $8 | $63.68 | $370.14 |
| EKG tracing only | CPT | 93005 | 10 | $391 | $234.6 | $54.55 | $62.56 | $363.63 |
| Transthoracic echocardiogram complete | CPT | 93306 | 10 | $3,393 | $2,035.8 | $503.56 | $542.88 | $3,155.49 |
| Stress echocardiogram | CPT | 93350 | 10 | $663 | $397.8 | $106.08 | $503.56 | $616.59 |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 9 | — | — | $10,729 | $13,497 | $22,674 |
| COPD w MCC | MS-DRG | 190 | 9 | — | — | $6,969.68 | $9,566.92 | $16,072 |
| COPD w CC | MS-DRG | 191 | 9 | — | — | $5,369.57 | $7,280.77 | $12,232 |
| COPD w/o CC/MCC | MS-DRG | 192 | 9 | — | — | $4,059.11 | $5,544.79 | $9,315.24 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 9 | — | — | $5,200.07 | $6,960.35 | $11,693 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 9 | — | — | $3,956.66 | $5,428.19 | $9,119.36 |
| AMI discharged alive w MCC | MS-DRG | 280 | 9 | — | — | $10,034 | $13,854 | $23,275 |
| AMI discharged alive w CC | MS-DRG | 281 | 9 | — | — | $5,774.34 | $7,938.03 | $13,336 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 9 | — | — | $4,541.68 | $6,245.23 | $10,492 |
| Heart failure & shock w MCC | MS-DRG | 291 | 9 | — | — | $8,120.13 | $11,088 | $18,628 |
| Heart failure & shock w CC | MS-DRG | 292 | 9 | — | — | $5,417 | $7,332.59 | $12,319 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 9 | — | — | $3,551.25 | $4,888.39 | $8,212.5 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 9 | — | — | $7,603.41 | $10,399 | $17,470 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 9 | — | — | $4,709.91 | $6,354.05 | $10,675 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 9 | — | — | $3,497.49 | $4,889.26 | $8,213.95 |
| GI hemorrhage w CC | MS-DRG | 378 | 9 | — | — | $6,222.12 | $8,470.05 | $14,230 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 9 | — | — | $4,004.72 | $5,444.6 | $9,146.93 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 9 | — | — | $4,968.59 | $6,733.2 | $11,312 |
| Kidney/UTI w MCC | MS-DRG | 689 | 9 | — | — | $7,427.58 | $10,021 | $16,836 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 9 | — | — | $5,103.3 | $6,991.44 | $11,746 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 9 | — | — | $12,539 | $16,777 | $28,185 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 9 | — | — | $6,513.68 | $8,837.98 | $14,848 |
| Hospital discharge, >30 min | CPT | 99239 | 6 | $198 | $118.8 | $72.89 | $103.34 | $103.34 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 10 | $240 | $144 | $5.69 | $8.46 | $223.2 |
| General health panel | CPT | 80050 | 8 | $457 | $274.2 | $10.26 | $307.56 | $425.01 |
| Electrolyte panel | CPT | 80051 | 10 | $192 | $115.2 | $4.75 | $7.01 | $178.56 |
| Comprehensive metabolic panel | CPT | 80053 | 10 | $248 | $148.8 | $7.15 | $10.56 | $230.64 |
| Lipid panel | CPT | 80061 | 10 | $351 | $210.6 | $9.68 | $13.39 | $326.43 |
| Renal function panel | CPT | 80069 | 10 | $338 | $202.8 | $5.69 | $8.68 | $314.34 |
| Hepatic function panel | CPT | 80076 | 10 | $298 | $178.8 | $5.69 | $47.68 | $277.14 |
| Urinalysis non-automated | CPT | 81002 | 10 | $60 | $36 | $2.05 | $13.8 | $55.8 |
| Urinalysis automated | CPT | 81003 | 10 | $90 | $54 | $1.91 | $16.41 | $83.7 |
| Glucose quantitative | CPT | 82947 | 10 | $194 | $116.4 | $3.34 | $3.93 | $180.42 |
| Hemoglobin A1c | CPT | 83036 | 10 | $118 | $70.8 | $8.25 | $9.71 | $109.74 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 10 | $265 | $159 | $14.28 | $16.8 | $246.45 |
| Complete blood count with automated differential | CPT | 85025 | 10 | $120 | $72 | $6.61 | $7.77 | $111.6 |
| Complete blood count without differential | CPT | 85027 | 10 | $92 | $55.2 | $5.5 | $14.72 | $85.56 |
| Urine culture bacterial | CPT | 87086 | 10 | $202 | $121.2 | $6.86 | $32.32 | $187.86 |
| Tissue exam by pathologist level IV | CPT | 88305 | 10 | $184 | $110.4 | $29.44 | $49.07 | $171.12 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 10 | $394 | $236.4 | $63.04 | $184.75 | $366.42 |
| office |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 8 | $857 | $514.2 | $137.12 | $576.76 | $797.01 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 8 | $1,104 | $662.4 | $176.64 | $742.99 | $1,026.72 |
| Office visit, established patient, 5 min | CPT | 99211 | 8 | $689 | $413.4 | $72.48 | $337.94 | $640.77 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 8 | $646 | $387.6 | $103.36 | $434.76 | $600.78 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 8 | $857 | $514.2 | $137.12 | $576.76 | $797.01 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 8 | $1,104 | $662.4 | $176.64 | $742.99 | $1,026.72 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 8 | $1,454 | $872.4 | $232.64 | $978.54 | $1,352.22 |
| surgery |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 9 | — | — | $28,567 | $39,699 | $66,694 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 9 | — | — | $15,003 | $20,704 | $34,783 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 9 | — | — | $10,575 | $14,535 | $24,418 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 9 | — | — | $10,339 | $14,610 | $24,545 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 9 | — | — | $8,305.44 | $11,796 | $19,817 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 9 | — | — | $18,651 | $25,153 | $42,257 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 9 | — | — | $13,123 | $18,090 | $30,391 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 9 | — | — | $7,349.16 | $10,716 | $18,002 |