| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $483.09 | $193.24 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $751.74 | $300.7 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $1,355.84 | $542.34 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $1,911.56 | $764.62 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $2,889.13 | $1,155.65 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $4,494.32 | $1,797.73 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $1,568 | $627.2 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $2,386.65 | $954.66 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $2,386.65 | $954.66 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $2,386.65 | $954.66 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $3,799.6 | $1,519.84 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $4,608.32 | $1,843.33 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $5,819.33 | $2,327.73 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $475.11 | $190.04 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $475.11 | $190.04 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $475.11 | $190.04 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $1,942.75 | $777.1 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $2,957.35 | $1,182.94 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $3,320.27 | $1,328.11 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $5,892.13 | $2,356.85 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $7,112.48 | $2,844.99 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $7,790.75 | $3,116.3 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $489.01 | $195.6 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $1,582.82 | $633.13 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $1,582.82 | $633.13 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $1,582.82 | $633.13 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $3,799.6 | $1,519.84 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $3,799.6 | $1,519.84 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $3,799.6 | $1,519.84 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $4,740.15 | $1,896.06 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $5,819.33 | $2,327.73 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $5,819.33 | $2,327.73 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $1,849.73 | $739.89 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $2,816.35 | $1,126.54 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $489.01 | $195.6 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $489.01 | $195.6 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $489.01 | $195.6 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $3,835.59 | $1,534.24 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $5,819.33 | $2,327.73 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $489.01 | $195.6 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $489.01 | $195.6 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $3,799.6 | $1,519.84 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $5,819.33 | $2,327.73 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $1,849.95 | $739.98 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $2,816.35 | $1,126.54 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $2,816.35 | $1,126.54 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $3,699.13 | $1,479.65 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $5,631.92 | $2,252.77 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $6,323.41 | $2,529.36 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $3,835.59 | $1,534.24 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $5,819.33 | $2,327.73 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,068.31 | $427.32 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,017.5 | $407 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,068.31 | $427.32 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $1,058.28 | $423.31 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,058.28 | $423.31 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $1,058.28 | $423.31 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $1,058.28 | $423.31 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,058.28 | $423.31 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $1,045.65 | $418.26 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,304.27 | $521.71 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,129.15 | $451.66 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $471.9 | $188.76 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $3,564.2 | $1,425.68 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $3,349.31 | $1,339.72 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $3,011.36 | $1,204.54 | — | — | — |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 0 | $52,163 | $20,865 | — | — | — |
| COPD w MCC | MS-DRG | 190 | 0 | $32,326 | $12,931 | — | — | — |
| COPD w/o CC/MCC | MS-DRG | 192 | 0 | $2,338.6 | $935.44 | — | — | — |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 0 | $53,243 | $21,297 | — | — | — |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 0 | $28,311 | $11,324 | — | — | — |
| AMI discharged alive w MCC | MS-DRG | 280 | 0 | $37,280 | $14,912 | — | — | — |
| AMI discharged alive w CC | MS-DRG | 281 | 0 | $20,396 | $8,158.5 | — | — | — |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 0 | $31,288 | $12,515 | — | — | — |
| Heart failure & shock w MCC | MS-DRG | 291 | 0 | $36,775 | $14,710 | — | — | — |
| Heart failure & shock w CC | MS-DRG | 292 | 0 | $33,504 | $13,401 | — | — | — |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 0 | $39,448 | $15,779 | — | — | — |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 0 | $25,748 | $10,299 | — | — | — |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 0 | $20,815 | $8,326.19 | — | — | — |
| GI hemorrhage w CC | MS-DRG | 378 | 0 | $50,622 | $20,249 | — | — | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 0 | $24,330 | $9,732.12 | — | — | — |
| Kidney/UTI w MCC | MS-DRG | 689 | 0 | $37,404 | $14,962 | — | — | — |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 0 | $29,411 | $11,764 | — | — | — |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 0 | $55,897 | $22,359 | — | — | — |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 0 | $26,098 | $10,439 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $106.43 | $42.57 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $91.9 | $36.76 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $108.01 | $43.2 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $177.54 | $71.02 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $106.43 | $42.57 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $106.43 | $42.57 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $42.22 | $16.89 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $52.57 | $21.03 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $129.08 | $51.63 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $216.02 | $86.41 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $103.22 | $41.29 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $86.27 | $34.51 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $146.51 | $58.6 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $126.43 | $50.57 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $434.17 | $173.67 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $838.61 | $335.44 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $11,899 | $4,759.64 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $276.87 | $110.75 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $360.69 | $144.28 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $444.59 | $177.84 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $528.42 | $211.37 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $192.98 | $77.19 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $586.61 | $234.64 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $360.69 | $144.28 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $447.5 | $179 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $528.42 | $211.37 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $5,367.67 | $2,147.07 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $5,666.06 | $2,266.42 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $4,309.22 | $1,723.69 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $4,740.15 | $1,896.06 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $5,580.37 | $2,232.15 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $5,580.37 | $2,232.15 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $5,580.37 | $2,232.15 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $48,073 | $19,229 | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $52,926 | $21,170 | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $53,658 | $21,463 | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $15,913 | $6,365.31 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $35,699 | $14,280 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $29,633 | $11,853 | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $42,715 | $17,086 | — | — | — |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 0 | $145,761 | $58,304 | — | — | — |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 0 | $100,837 | $40,335 | — | — | — |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 0 | $87,859 | $35,144 | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 0 | $69,923 | $27,969 | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 0 | $69,880 | $27,952 | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $39,951 | $15,980 | — | — | — |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 0 | $293,456 | $117,382 | — | — | — |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 0 | $142,388 | $56,955 | — | — | — |
| Major joint replacement w MCC | MS-DRG | 469 | 0 | $78,013 | $31,205 | — | — | — |
| Major joint replacement w/o MCC | MS-DRG | 470 | 0 | $64,244 | $25,698 | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $35,276 | $14,110 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $41,220 | $16,488 | — | — | — |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 0 | $89,377 | $35,751 | — | — | — |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 0 | $77,546 | $31,018 | — | — | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 0 | $61,725 | $24,690 | — | — | — |
| Lap inguinal hernia repair | CPT | 49650 | 0 | $41,344 | $16,538 | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | $21,820 | $8,728.06 | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $21,662 | $8,664.66 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $20,248 | $8,099.07 | — | — | — |
| Complex cataract surgery | CPT | 66982 | 0 | $13,764 | $5,505.79 | — | — | — |
| Cataract surgery with lens implant | CPT | 66984 | 0 | $8,450.14 | $3,380.05 | — | — | — |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 0 | $67,527 | $27,011 | — | — | — |
| PCI single major coronary artery | CPT | 92920 | 0 | $21,969 | $8,787.61 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $35,681 | $14,272 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $35,681 | $14,272 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $21,219 | $8,487.43 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $21,219 | $8,487.43 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $21,219 | $8,487.43 | — | — | — |
