| behavioral |
| Psychoses | MS-DRG | 885 | 6 | — | $13,276 | $10,754 | $13,276 | $18,457 |
| Psychiatric diagnostic evaluation | CPT | 90791 | 13 | — | — | $43.62 | $151 | $613.98 |
| Psychiatric eval with medical services | CPT | 90792 | 8 | — | — | $179.47 | $221.56 | $613.98 |
| Psychotherapy 30 minutes | CPT | 90832 | 13 | — | — | $18.22 | $70.44 | $613.98 |
| Psychotherapy 45 minutes | CPT | 90834 | 13 | — | — | $27.31 | $93.37 | $613.98 |
| Psychotherapy 60 minutes | CPT | 90837 | 13 | — | — | $41.23 | $137.27 | $613.98 |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 13 | — | — | $68.47 | $137.64 | $613.98 |
| emergency |
| ED visit level 1 | CPT | 99281 | 13 | $389 | $194 | $5.81 | $16.53 | $291.69 |
| ED visit level 2 | CPT | 99282 | 13 | $682 | $341 | $10.92 | $40.8 | $531.13 |
| ED visit level 3 | CPT | 99283 | 13 | $1,073 | $536 | $17.64 | $68.14 | $944.26 |
| ED visit level 4 | CPT | 99284 | 13 | $1,792 | $896 | $32.52 | $117.76 | $1,443.36 |
| ED visit level 5 | CPT | 99285 | 13 | $2,638 | $1,319 | $48.54 | $170.78 | $2,060.01 |
| Critical care, first hour | CPT | 99291 | 13 | $2,742 | $1,371 | $71.98 | $248.99 | $2,857.33 |
| imaging |
| CT head without contrast | CPT | 70450 | 11 | $607 | $304 | $72.72 | $121.2 | $361.64 |
| CT head with contrast | CPT | 70460 | 11 | $877 | $438 | $87.87 | $161.1 | $606.73 |
| CT head with and without contrast | CPT | 70470 | 11 | $1,029 | $514 | $131.5 | $219.17 | $606.73 |
| CT neck with contrast | CPT | 70491 | 11 | $877 | $438 | $103.02 | $174.53 | $606.73 |
| MRI brain without contrast | CPT | 70551 | 11 | $1,184 | $592 | $175.93 | $434.3 | $1,136.25 |
| MRI brain with contrast | CPT | 70552 | 11 | $1,436 | $718 | $260.33 | $492.02 | $1,206.79 |
| MRI brain with and without contrast | CPT | 70553 | 11 | $1,814 | $907 | $296.62 | $492.02 | $1,206.79 |
| Chest X-ray single view | CPT | 71045 | 14 | $294 | $147 | $5.75 | $15.33 | $301.03 |
| Chest X-ray 2 views | CPT | 71046 | 14 | $294 | $147 | $6.87 | $21 | $301.03 |
| Chest X-ray 3 views | CPT | 71047 | 11 | $294 | $147 | $9.09 | $18.41 | $301.03 |
| CT chest without contrast | CPT | 71250 | 11 | $607 | $304 | $84.84 | $141.4 | $361.64 |
| CT chest with contrast | CPT | 71260 | 11 | $877 | $438 | $103.02 | $174.53 | $606.73 |
| CT chest with and without contrast | CPT | 71270 | 11 | $1,019 | $510 | $153.92 | $248.69 | $606.73 |
| MRI chest without contrast | CPT | 71550 | 11 | $1,184 | $592 | $241.25 | $434.3 | $1,136.25 |
| MRI chest with contrast | CPT | 71551 | 11 | $1,436 | $718 | $303 | $555.5 | $2,711.68 |
| MRI chest with and without contrast | CPT | 71552 | 11 | $1,814 | $907 | $303 | $492.02 | $1,206.79 |
| Lumbosacral spine X-ray | CPT | 72100 | 14 | $346 | $173 | $6.46 | $22.41 | $361.64 |
| CT cervical spine without contrast | CPT | 72125 | 11 | $607 | $304 | $84.84 | $141.4 | $361.64 |
| CT thoracic spine without contrast | CPT | 72128 | 11 | $607 | $304 | $84.84 | $141.4 | $361.64 |
| CT lumbar spine without contrast | CPT | 72131 | 11 | $607 | $304 | $84.84 | $141.4 | $361.64 |
| MRI cervical spine without contrast | CPT | 72141 | 11 | $1,184 | $592 | $168.92 | $434.3 | $1,136.25 |
| MRI thoracic spine without contrast | CPT | 72146 | 11 | $1,184 | $592 | $169.35 | $434.3 | $1,136.25 |
| MRI lumbar spine without contrast | CPT | 72148 | 11 | $1,184 | $592 | $169.35 | $434.3 | $1,136.25 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 11 | $1,436 | $718 | $262.39 | $492.02 | $1,206.79 |
| MRI cervical spine with and without contrast | CPT | 72156 | 11 | $1,814 | $907 | $299.51 | $492.02 | $1,206.79 |
| MRI lumbar spine with contrast | CPT | 72158 | 11 | $1,814 | $907 | $298.68 | $492.02 | $1,206.79 |
| CT pelvis without contrast | CPT | 72192 | 11 | $607 | $304 | $84.84 | $141.4 | $361.64 |
| CT pelvis with contrast | CPT | 72193 | 11 | $877 | $438 | $103.02 | $179.59 | $606.73 |
| Shoulder X-ray | CPT | 73030 | 14 | $308 | $154 | $5.53 | $20.01 | $301.03 |
| Humerus X-ray | CPT | 73060 | 14 | $308 | $154 | $4.82 | $16.12 | $301.03 |
| Hand X-ray 3 views | CPT | 73130 | 14 | $308 | $154 | $4.63 | $17.63 | $301.03 |
| MRI upper extremity joint without contrast | CPT | 73221 | 11 | $1,184 | $592 | $190.64 | $434.3 | $1,136.25 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 11 | $1,814 | $907 | $303 | $492.02 | $1,206.79 |
| Knee X-ray 1-2 views | CPT | 73560 | 14 | $308 | $154 | $5.16 | $16.83 | $301.03 |
| Ankle X-ray 3 views | CPT | 73610 | 14 | $308 | $154 | $4.63 | $17.82 | $301.03 |
| MRI lower extremity joint without contrast | CPT | 73721 | 11 | $1,184 | $592 | $190.64 | $434.3 | $1,136.25 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 11 | $1,814 | $907 | $303 | $492.02 | $1,206.79 |
| CT abdomen without contrast | CPT | 74150 | 11 | $607 | $304 | $84.84 | $141.4 | $361.64 |
| CT abdomen with contrast | CPT | 74160 | 11 | $877 | $438 | $103.02 | $179.59 | $606.73 |
| CT abdomen with and without contrast | CPT | 74170 | 11 | $1,029 | $514 | $153.92 | $248.69 | $606.73 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 11 | $923 | $462 | $41.63 | $84.29 | $825.35 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 11 | $1,338 | $669 | $65.41 | $132.45 | $1,206.79 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 11 | $1,567 | $784 | $82.86 | $167.8 | $1,206.79 |
| MRI abdomen without contrast | CPT | 74181 | 11 | $1,184 | $592 | $184.16 | $434.3 | $1,136.25 |
| MRI abdomen with and without contrast | CPT | 74183 | 11 | $1,814 | $907 | $303 | $492.02 | $1,206.79 |
| Abdominal ultrasound complete | CPT | 76700 | 14 | $577 | $288 | $21.84 | $78.85 | $361.64 |
| Abdominal ultrasound limited | CPT | 76705 | 14 | $654 | $327 | $15.92 | $56.33 | $361.64 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 14 | $554 | $277 | $19.98 | $75.15 | $361.64 |
| Obstetric ultrasound first trimester | CPT | 76801 | 11 | $566 | $283 | $33.33 | $67.5 | $361.64 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 11 | $566 | $283 | $33.33 | $67.5 | $361.64 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 13 | $787 | $394 | $43.63 | $112.27 | $825.35 |
| Transvaginal ultrasound | CPT | 76830 | 13 | $472 | $236 | $21.71 | $73.63 | $361.64 |
| Pelvic ultrasound complete | CPT | 76856 | 11 | $566 | $283 | $33.33 | $67.5 | $361.64 |
| Scrotal ultrasound | CPT | 76870 | 14 | $665 | $332 | $17.57 | $62.11 | $361.64 |
| Diagnostic mammography unilateral | CPT | 77065 | 11 | $575 | $288 | $58.78 | $95.05 | $226.62 |
| Diagnostic mammography bilateral | CPT | 77066 | 11 | $704 | $352 | $58.78 | $101.42 | $290.58 |
| Screening mammography bilateral | CPT | 77067 | 11 | $627 | $314 | $58.78 | $97.64 | $239.81 |
| EKG complete | CPT | 93000 | 14 | $150 | — | $9.34 | $15.15 | $40.79 |
| EKG tracing only | CPT | 93005 | 14 | $249 | $124 | $4.03 | $7.58 | $204.06 |
| EKG interpretation only | CPT | 93010 | 13 | $47 | $28.03 | $5.31 | $8.13 | $22.53 |
| Transthoracic echocardiogram complete | CPT | 93306 | 14 | $2,151 | $1,076 | $44.9 | $177.1 | $1,890.11 |
| Transthoracic echocardiogram | CPT | 93307 | 11 | $2,662 | $1,331 | $54.54 | $110.45 | $825.35 |
| Stress echocardiogram | CPT | 93350 | 11 | $2,823 | $1,412 | $72.72 | $147.26 | $1,890.11 |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 6 | — | $14,771 | $11,965 | $14,771 | $20,650 |
| COPD w MCC | MS-DRG | 190 | 6 | — | $10,670 | $8,544.8 | $10,670 | $14,637 |
| COPD w CC | MS-DRG | 191 | 6 | — | $8,284.36 | $6,502.9 | $8,284.36 | $11,139 |
| COPD w/o CC/MCC | MS-DRG | 192 | 6 | — | $6,472.67 | $4,952.39 | $6,472.67 | $8,483.39 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 6 | — | $7,949.96 | $6,216.71 | $7,949.96 | $10,649 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 6 | — | $6,350.99 | $4,848.25 | $6,350.99 | $8,305 |
| AMI discharged alive w MCC | MS-DRG | 280 | 6 | — | $15,144 | $12,267 | $15,144 | $21,197 |
| AMI discharged alive w CC | MS-DRG | 281 | 6 | — | $8,970.28 | $7,089.94 | $8,970.28 | $12,145 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 6 | — | $7,203.66 | $5,577.99 | $7,203.66 | $9,555.04 |
| Heart failure & shock w MCC | MS-DRG | 291 | 6 | — | $12,257 | $9,903.23 | $12,257 | $16,964 |
| Heart failure & shock w CC | MS-DRG | 292 | 6 | — | $8,338.44 | $6,549.19 | $8,338.44 | $11,219 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 6 | — | $5,787.66 | $4,366.12 | $5,787.66 | $7,479.12 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 6 | — | $11,538 | $9,287.66 | $11,538 | $15,910 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 6 | — | $7,317.23 | $5,675.19 | $7,317.23 | $9,721.54 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 6 | — | $5,788.56 | $4,366.9 | $5,788.56 | $7,480.45 |
| GI hemorrhage w CC | MS-DRG | 378 | 6 | — | $9,525.5 | $7,565.12 | $9,525.5 | $12,959 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 6 | — | $6,368.12 | $4,862.91 | $6,368.12 | $8,330.11 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 6 | — | $7,712.91 | $6,013.83 | $7,712.91 | $10,302 |
| Fractures of femur w/o MCC | MS-DRG | 533 | 6 | — | $14,816 | $12,001 | $14,816 | $20,716 |
| Kidney/UTI w MCC | MS-DRG | 689 | 6 | — | $11,144 | $8,950.55 | $11,144 | $15,332 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 6 | — | $7,982.41 | $6,244.48 | $7,982.41 | $10,697 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 6 | — | $18,195 | $14,738 | $18,195 | $25,668 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 6 | — | $9,909.47 | $7,893.74 | $9,909.47 | $13,522 |
| Initial hospital care, low complexity | CPT | 99221 | 13 | $197 | $117.47 | $25.47 | $77.66 | $203.44 |
| Initial hospital care, moderate complexity | CPT | 99222 | 13 | $266 | $158.62 | $35.08 | $121.85 | $319.71 |
| Initial hospital care, high complexity | CPT | 99223 | 13 | $395 | $235.54 | $51.54 | $164.2 | $426.74 |
| Hospital discharge, <30 min | CPT | 99238 | 13 | $141 | $84.08 | $19.52 | $72.59 | $201.15 |
| Hospital discharge, >30 min | CPT | 99239 | 13 | $208 | $124.03 | $27.97 | $103.49 | $286.78 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 11 | $48 | $24 | $5.64 | $7.95 | $16.48 |
| General health panel | CPT | 80050 | 1 | $211 | $106 | $42.99 | $43.48 | $43.48 |
| Electrolyte panel | CPT | 80051 | 11 | $39 | $20 | $4.68 | $6.59 | $13.73 |
| Comprehensive metabolic panel | CPT | 80053 | 11 | $62 | $31 | $7.03 | $10.1 | $22.72 |
| Lipid panel | CPT | 80061 | 11 | $84 | $42 | $6.1 | $11.92 | $15.04 |
| Renal function panel | CPT | 80069 | 11 | $50 | $25 | $5.78 | $8.68 | $19.53 |
| Hepatic function panel | CPT | 80076 | 11 | $48 | $24 | $5.44 | $7.68 | $16.48 |
| Urinalysis non-automated | CPT | 81002 | 14 | $10 | $5 | $1.72 | $2.96 | $4.55 |
| Urinalysis automated | CPT | 81003 | 14 | $9 | $4 | $1.35 | $2.02 | $4.55 |
| Glucose quantitative | CPT | 82947 | 14 | $26 | $13 | $2.36 | $3.93 | $8.84 |
| Hemoglobin A1c | CPT | 83036 | 14 | $58 | $29 | $4.08 | $9.71 | $21.85 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 14 | $99 | $50 | $7.06 | $14.28 | $20.45 |
| Complete blood count with automated differential | CPT | 85025 | 11 | $48 | $24 | $3.2 | $6.92 | $8.73 |
| Complete blood count without differential | CPT | 85027 | 11 | $39 | $20 | $3.2 | $5.76 | $7.27 |
| Urine culture bacterial | CPT | 87086 | 14 | $50 | $25 | $3.39 | $8.07 | $18.16 |
| Urine culture identification | CPT | 87088 | 14 | $50 | $25 | $3.4 | $8.09 | $18.2 |
| Tissue exam by pathologist level IV | CPT | 88305 | 14 | $174 | $94.81 | $8.98 | $52.52 | $175.06 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 14 | $801 | $400 | $9.09 | $34.44 | $699.33 |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 11 | $3,957 | $2,359.56 | $1,420.74 | $2,137.63 | $5,817.45 |
| Vaginal delivery only | CPT | 59409 | 13 | $1,551 | $924.86 | $513.12 | $802.53 | $11,198 |
| Vaginal delivery with postpartum | CPT | 59410 | 11 | $3,871 | $2,308.28 | $694.65 | $970.55 | $2,566.95 |
| Routine obstetric care with C-section | CPT | 59510 | 11 | $4,369 | $2,605.23 | $1,420.74 | $2,363.24 | $6,416.42 |
| C-section delivery only | CPT | 59514 | 11 | $1,741 | $1,038.16 | $579.97 | $832.48 | $2,187.94 |
| C-section with postpartum | CPT | 59515 | 11 | $2,394 | — | $735.82 | $1,187.59 | $3,150.23 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 13 | $130 | $77.52 | $16.03 | $54.31 | $366 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 13 | $180 | $107.33 | $24.6 | $88.65 | $490 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 13 | $250 | $149.08 | $40.88 | $134.64 | $518 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 13 | $320 | $190.82 | $53.17 | $176.92 | $538.85 |
| Office visit, established patient, 5 min | CPT | 99211 | 13 | $325 | $162 | $3.15 | $14.36 | $285 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 13 | $370 | $185 | $8.3 | $38.59 | $366 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 13 | $420 | $210 | $17.57 | $64.55 | $490 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 13 | $490 | $245 | $24.59 | $95.41 | $518 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 13 | $560 | $280 | $35.33 | $136.23 | $439.59 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 13 | $3,051 | $1,526 | $67.2 | $235.71 | $3,137.37 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 13 | $1,185 | $706.62 | $84 | $302.37 | $3,137.37 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 13 | $255 | $152.06 | $24.7 | $145.73 | $3,216.83 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 13 | $498 | $296.96 | $29.69 | $220.08 | $3,216.83 |
| Colonoscopy diagnostic | CPT | 45378 | 13 | $2,967 | $1,484 | $85.86 | $281.35 | $3,216.83 |
| Colonoscopy with biopsy | CPT | 45380 | 13 | $1,323 | $788.9 | $129.87 | $351.24 | $4,139.33 |
| Colonoscopy with polyp removal | CPT | 45385 | 13 | $3,837 | $1,918 | $122.15 | $375.11 | $4,139.33 |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 13 | $59,846 | $29,923 | $607.5 | $1,412.33 | $60,652 |
| Hip hemiarthroplasty | CPT | 27125 | 13 | $3,180 | $1,896.23 | $449.32 | $1,081.49 | $44,411 |
| Total hip replacement | CPT | 27130 | 13 | $3,820 | $2,277.87 | $579.91 | $1,255.9 | $44,411 |
| Total knee replacement | CPT | 27447 | 13 | $3,815 | $2,274.88 | $623 | $1,300.54 | $44,411 |
| Knee revision arthroplasty single component | CPT | 27486 | 13 | $3,937 | $2,347.63 | $568.34 | $1,338.76 | $44,411 |
| Knee revision arthroplasty all components | CPT | 27487 | 13 | — | — | $716.69 | $1,666.62 | $60,652 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 11 | $9,677 | $4,838 | $111.23 | $179.71 | $574.74 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 13 | $23,247 | $11,624 | $442.28 | $1,048.97 | $25,100 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 13 | $10,559 | $5,280 | $256.22 | $544.46 | $11,318 |
| ACL reconstruction | CPT | 29888 | 13 | $2,912 | $1,736.43 | $399.19 | $956.98 | $25,100 |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 6 | — | $42,116 | $34,114 | $42,116 | $60,738 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 6 | — | $22,293 | $18,057 | $22,293 | $31,677 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 6 | — | $15,855 | $12,842 | $15,855 | $22,238 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 6 | — | $15,933 | $12,906 | $15,933 | $22,353 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 6 | — | $12,997 | $10,527 | $12,997 | $18,048 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 6 | — | $31,396 | $25,430 | $31,396 | $45,021 |
| Open appendectomy | CPT | 44950 | 13 | $1,233 | $735.24 | $242.82 | $626.71 | $22,394 |
| Laparoscopic appendectomy | CPT | 44970 | 13 | $1,127 | $672.03 | $222.75 | $588.13 | $20,912 |
| Major joint replacement w MCC | MS-DRG | 469 | 6 | — | $28,025 | $22,701 | $28,025 | $40,081 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 6 | — | $18,072 | $14,638 | $18,072 | $25,488 |
| Laparoscopic cholecystectomy | CPT | 47562 | 13 | $1,272 | $758.49 | $277.43 | $640.6 | $20,912 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 13 | $1,373 | $818.72 | $285.86 | $696.38 | $20,912 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 6 | — | $26,936 | $21,818 | $26,936 | $38,483 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 6 | — | $19,565 | $15,847 | $19,565 | $27,677 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 6 | — | $15,387 | $12,463 | $15,387 | $21,552 |
| Lap inguinal hernia repair | CPT | 49650 | 13 | $804 | $479.43 | $160.98 | $419.67 | $20,912 |
| Total abdominal hysterectomy | CPT | 58150 | 13 | $1,913 | $1,140.72 | $395.94 | $918.73 | $2,487.84 |
| Vaginal hysterectomy | CPT | 58260 | 13 | $1,559 | $929.63 | $332.51 | $806.44 | $17,304 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 13 | $1,665 | $992.84 | $356.6 | $847.58 | $20,912 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 13 | $1,866 | $1,112.7 | $392.54 | $941.43 | $36,770 |
| Lap salpingo-oophorectomy | CPT | 58661 | 13 | $1,709 | $1,019.08 | $260.86 | $657.45 | $20,912 |
| OR procedure for obesity w MCC | MS-DRG | 619 | 6 | — | $26,711 | $21,636 | $26,711 | $38,154 |
| OR procedure for obesity w CC | MS-DRG | 620 | 6 | — | $15,110 | $12,239 | $15,110 | $21,146 |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 6 | — | $14,282 | $11,568 | $14,282 | $19,932 |
| Complex cataract surgery | CPT | 66982 | 8 | — | — | $2,333.46 | $2,880.82 | $7,983.04 |
| Cataract surgery with lens implant | CPT | 66984 | 8 | — | — | $2,333.46 | $2,880.82 | $7,983.04 |
| Intravitreal injection | CPT | 67028 | 8 | — | — | $333.98 | $412.32 | $1,142.57 |
| Vitrectomy mechanical | CPT | 67042 | 8 | — | — | $4,179.34 | $5,159.69 | $14,298 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 6 | — | $11,869 | $9,570.76 | $11,869 | $16,395 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 6 | — | $19,155 | $15,516 | $19,155 | $27,077 |
| PCI single major coronary artery | CPT | 92920 | 8 | — | — | $649.29 | $7,104.69 | $19,688 |
| PCI with drug-eluting stent | CPT | 92928 | 8 | — | — | $722.37 | $14,410 | $39,933 |
| PCI bypass graft | CPT | 92937 | 8 | — | — | $721.52 | $14,410 | $39,933 |
| Left heart catheterization | CPT | 93452 | 8 | — | — | $892.95 | $4,046.85 | $11,214 |
| Coronary angiography with cath | CPT | 93455 | 8 | — | — | $988.75 | $4,046.85 | $11,214 |
| Coronary angiography with bypass cath | CPT | 93458 | 8 | — | — | $1,007.65 | $4,046.85 | $11,214 |