| behavioral |
| Psychoses | MS-DRG | 885 | 12 | — | $2,726 | $60 | $13,386 | $28,092 |
| Psychiatric diagnostic evaluation | CPT | 90791 | 12 | $858 | $161.04 | $22.58 | $440.52 | $835.52 |
| Psychiatric eval with medical services | CPT | 90792 | 12 | $965 | $181.13 | $158.74 | $520.83 | $939.71 |
| Psychotherapy 30 minutes | CPT | 90832 | 12 | $461 | $86.52 | $75.83 | $293.97 | $734.77 |
| Psychotherapy 45 minutes | CPT | 90834 | 12 | $518 | $97.22 | $85.21 | $330.32 | $734.77 |
| Psychotherapy 60 minutes | CPT | 90837 | 12 | $567 | $106.42 | $90.26 | $351.18 | $734.77 |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 12 | $667 | $125.19 | $74.35 | $400.2 | $734.77 |
| emergency |
| ED visit level 1 | CPT | 99281 | 13 | $1,052 | $197.46 | $5.69 | $241.42 | $1,339 |
| ED visit level 2 | CPT | 99282 | 13 | $1,427 | $267.84 | $20.76 | $398 | $1,339 |
| ED visit level 3 | CPT | 99283 | 13 | $2,261 | $424.38 | $36.71 | $759.19 | $1,562 |
| ED visit level 4 | CPT | 99284 | 13 | $3,099 | $581.68 | $62.43 | $1,056 | $2,186 |
| ED visit level 5 | CPT | 99285 | 13 | $4,357 | $817.8 | $90.41 | $1,056 | $2,803.85 |
| Critical care, first hour | CPT | 99291 | 13 | $5,566 | $1,044.73 | $144.26 | $1,832.53 | $4,708.83 |
| imaging |
| CT head without contrast | CPT | 70450 | 13 | $2,085 | $391.35 | $56.31 | $281 | $1,329.6 |
| CT head with contrast | CPT | 70460 | 13 | $2,305 | $432.64 | $78.83 | $346.21 | $1,469.89 |
| CT head with and without contrast | CPT | 70470 | 13 | $2,934 | $550.71 | $92.36 | $387.15 | $1,871.01 |
| CT neck with contrast | CPT | 70491 | 13 | $3,005 | $564.03 | $98.03 | $384.2 | $1,916.28 |
| MRI brain without contrast | CPT | 70551 | 13 | $3,279 | $615.46 | $104.6 | $492.5 | $2,091.01 |
| MRI brain with contrast | CPT | 70552 | 13 | $3,615 | $678.53 | $144.46 | $603.32 | $2,305.28 |
| MRI brain with and without contrast | CPT | 70553 | 13 | $5,038 | $945.63 | $169.89 | $756.7 | $3,212.73 |
| Chest X-ray single view | CPT | 71045 | 13 | $494 | $92.72 | $13.32 | $116.42 | $402.68 |
| Chest X-ray 2 views | CPT | 71046 | 13 | $510 | $95.72 | $17.49 | $121.37 | $402.68 |
| Chest X-ray 3 views | CPT | 71047 | 13 | $541 | $101.54 | $22 | $126.1 | $402.68 |
| CT chest without contrast | CPT | 71250 | 13 | $2,195 | $412 | $70.62 | $281 | $1,399.75 |
| CT chest with contrast | CPT | 71260 | 13 | $2,983 | $559.9 | $88.96 | $387.15 | $1,902.25 |
| CT chest with and without contrast | CPT | 71270 | 13 | $3,652 | $685.48 | $104.66 | $389.1 | $2,328.88 |
| MRI chest without contrast | CPT | 71550 | 13 | $2,920 | $548.08 | $159.53 | $480.34 | $2,573.54 |
| MRI chest with contrast | CPT | 71551 | 13 | $3,808 | $714.76 | $200.48 | $992.61 | $3,613.15 |
| MRI chest with and without contrast | CPT | 71552 | 13 | $4,726 | $887.07 | $249.57 | $776.7 | $3,798.62 |
| Lumbosacral spine X-ray | CPT | 72100 | 13 | $533 | $100.04 | $20.82 | $143.22 | $486.33 |
| CT cervical spine without contrast | CPT | 72125 | 13 | $2,209 | $414.62 | $69.14 | $281 | $1,408.67 |
| CT thoracic spine without contrast | CPT | 72128 | 13 | $2,008 | $376.9 | $68.96 | $281 | $1,280.5 |
| CT lumbar spine without contrast | CPT | 72131 | 13 | $2,093 | $392.85 | $68.62 | $281 | $1,334.7 |
| MRI cervical spine without contrast | CPT | 72141 | 13 | $2,756 | $517.3 | $101.61 | $436 | $1,757.5 |
| MRI thoracic spine without contrast | CPT | 72146 | 13 | $2,996 | $562.34 | $101.44 | $449.99 | $1,910.54 |
| MRI lumbar spine without contrast | CPT | 72148 | 13 | $2,854 | $535.69 | $101.97 | $436 | $1,819.99 |
| MRI lumbar spine with and without contrast | CPT | 72149 | 13 | $3,356 | $629.92 | $144.63 | $603.32 | $2,140.12 |
| MRI cervical spine with and without contrast | CPT | 72156 | 13 | $4,909 | $921.41 | $170.77 | $737.33 | $3,130.46 |
| MRI lumbar spine with contrast | CPT | 72158 | 13 | $4,859 | $912.03 | $170.42 | $729.82 | $3,098.58 |
| CT pelvis without contrast | CPT | 72192 | 13 | $2,020 | $379.15 | $70.61 | $281 | $1,288.15 |
| CT pelvis with contrast | CPT | 72193 | 13 | $2,563 | $481.07 | $121.25 | $384.96 | $1,813.28 |
| Shoulder X-ray | CPT | 73030 | 14 | $1,140 | — | $15.02 | $96.23 | $402.68 |
| Humerus X-ray | CPT | 73060 | 14 | $519 | — | $15.02 | $96.23 | $402.68 |
| Hand X-ray 3 views | CPT | 73130 | 14 | $1,074 | — | $15.02 | $96.23 | $402.68 |
| MRI upper extremity joint without contrast | CPT | 73221 | 14 | $3,173 | — | $15.02 | $331.78 | $1,475.5 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 14 | $4,658 | — | $15.02 | $464.85 | $2,976.33 |
| Knee X-ray 1-2 views | CPT | 73560 | 14 | $1,072 | — | $15.02 | $96.23 | $402.68 |
| Ankle X-ray 3 views | CPT | 73610 | 14 | $958 | — | $15.02 | $96.23 | $402.68 |
| MRI lower extremity joint without contrast | CPT | 73721 | 14 | $2,458 | — | $15.02 | $331.78 | $1,472.05 |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 14 | $4,353 | — | $15.02 | $464.85 | $2,965.98 |
| CT abdomen without contrast | CPT | 74150 | 13 | $2,001 | $375.58 | $72.44 | $281 | $1,276.03 |
| CT abdomen with contrast | CPT | 74160 | 13 | $2,990 | $561.22 | $123.94 | $387.15 | $1,906.72 |
| CT abdomen with and without contrast | CPT | 74170 | 13 | $3,739 | $701.81 | $126.8 | $389.1 | $2,384.36 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 13 | $3,040 | $570.6 | $96.95 | $368.2 | $1,938.6 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 13 | $3,605 | $676.65 | $161.98 | $593.02 | $2,298.9 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 13 | $4,549 | $853.84 | $181.76 | $603.32 | $2,900.89 |
| MRI abdomen without contrast | CPT | 74181 | 13 | $3,098 | $581.49 | $104.44 | $509.62 | $1,975.59 |
| MRI abdomen with and without contrast | CPT | 74183 | 13 | $4,542 | $852.53 | $180.69 | $747.15 | $2,896.43 |
| Abdominal ultrasound complete | CPT | 76700 | 13 | $1,091 | $204.78 | $48.09 | $179.46 | $797.77 |
| Abdominal ultrasound limited | CPT | 76705 | 13 | $942 | $176.81 | $45.18 | $177.09 | $608.9 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 13 | $994 | $186.57 | $56.25 | $177.09 | $753 |
| Obstetric ultrasound first trimester | CPT | 76801 | 13 | $743 | $139.46 | $60.73 | $177.09 | $719.05 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 13 | $931 | $174.74 | $70.38 | $177.09 | $897.56 |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 13 | $923 | $173.24 | $91.38 | $368.2 | $1,105.45 |
| Transvaginal ultrasound | CPT | 76830 | 13 | $1,069 | $200.65 | $62.09 | $177.09 | $876.95 |
| Pelvic ultrasound complete | CPT | 76856 | 13 | $1,138 | $213.6 | $54.72 | $177.09 | $746.1 |
| Scrotal ultrasound | CPT | 76870 | 13 | $908 | $170.43 | $51.97 | $177.09 | $718.59 |
| Diagnostic mammography unilateral | CPT | 77065 | 9 | $619 | — | $15.02 | $91.18 | $904.46 |
| Diagnostic mammography bilateral | CPT | 77066 | 8 | $783 | $146.96 | $82.47 | $331.44 | $1,152.34 |
| Screening mammography bilateral | CPT | 77067 | 8 | $634 | $119 | $66.58 | $268.37 | $953.13 |
| EKG complete | CPT | 93000 | 9 | — | — | $7.36 | $77.17 | $334 |
| EKG tracing only | CPT | 93005 | 13 | $359 | $67.38 | $3.34 | $215.4 | $470.02 |
| EKG interpretation only | CPT | 93010 | 9 | — | — | $4.03 | $54.66 | $97.38 |
| Transthoracic echocardiogram complete | CPT | 93306 | 13 | $4,118 | $772.94 | $101.82 | $1,524.24 | $4,338.43 |
| Transthoracic echocardiogram | CPT | 93307 | 13 | $2,033 | $381.59 | $70.8 | $848.43 | $1,979.73 |
| Stress echocardiogram | CPT | 93350 | 13 | $2,547 | $478.07 | $96.03 | $1,344.39 | $4,338.43 |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 13 | — | $2,726 | $60 | $23,098 | $43,143 |
| COPD w MCC | MS-DRG | 190 | 13 | — | $2,726 | $60 | $14,494 | $29,972 |
| COPD w CC | MS-DRG | 191 | 13 | — | $2,726 | $60 | $11,427 | $22,929 |
| COPD w/o CC/MCC | MS-DRG | 192 | 13 | — | $2,726 | $60 | $8,754.16 | $17,273 |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 13 | — | $2,726 | $60 | $11,215 | $21,885 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 13 | — | $2,726 | $60 | $8,533.19 | $16,619 |
| AMI discharged alive w MCC | MS-DRG | 280 | 13 | — | $2,726 | $60 | $21,063 | $43,807 |
| AMI discharged alive w CC | MS-DRG | 281 | 13 | — | $2,726 | $60 | $12,424 | $24,602 |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 13 | — | $2,726 | $60 | $9,452.84 | $19,352 |
| Heart failure & shock w MCC | MS-DRG | 291 | 13 | — | $2,726 | $60 | $17,512 | $34,824 |
| Heart failure & shock w CC | MS-DRG | 292 | 13 | — | $2,726 | $60 | $11,683 | $22,985 |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 13 | — | $2,726 | $60 | $7,658.86 | $14,644 |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 13 | — | $2,726 | $60 | $15,500 | $32,184 |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 13 | — | $2,726 | $60 | $9,812.13 | $19,731 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 13 | — | $2,726 | $60 | $7,142.09 | $14,933 |
| GI hemorrhage w CC | MS-DRG | 378 | 13 | — | $2,726 | $60 | $12,688 | $26,313 |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 13 | — | $2,726 | $60 | $8,366.72 | $16,993 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 13 | — | $2,726 | $60 | $9,777.96 | $20,825 |
| Fractures of femur w/o MCC | MS-DRG | 533 | 13 | — | $2,726 | $60 | $19,696 | $40,698 |
| Kidney/UTI w MCC | MS-DRG | 689 | 13 | — | $2,726 | $60 | $14,460 | $31,234 |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 13 | — | $2,726 | $60 | $10,191 | $21,421 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 13 | — | $2,726 | $60 | $24,190 | $52,366 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 13 | — | $2,726 | $60 | $13,290 | $27,516 |
| Initial hospital care, low complexity | CPT | 99221 | 9 | — | — | $15.02 | $91.18 | $9,368 |
| Initial hospital care, moderate complexity | CPT | 99222 | 10 | — | — | $15.02 | $1,526.92 | $9,368 |
| Initial hospital care, high complexity | CPT | 99223 | 10 | — | — | $15.02 | $1,526.92 | $9,368 |
| Hospital discharge, <30 min | CPT | 99238 | 10 | — | — | $15.02 | $1,526.92 | $9,368 |
| Hospital discharge, >30 min | CPT | 99239 | 10 | — | — | $15.02 | $1,526.92 | $9,368 |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 13 | $164 | $9.31 | $3.98 | $16.92 | $104.58 |
| General health panel | CPT | 80050 | 9 | — | — | $16.45 | $63.77 | $161.56 |
| Electrolyte panel | CPT | 80051 | 13 | $133 | $7.71 | $3.29 | $14.02 | $84.81 |
| Comprehensive metabolic panel | CPT | 80053 | 13 | $328 | $11.62 | $4.96 | $21.12 | $209.16 |
| Lipid panel | CPT | 80061 | 13 | $247 | $14.73 | $6.29 | $26.78 | $157.51 |
| Renal function panel | CPT | 80069 | 13 | $210 | $9.55 | $4.08 | $17.27 | $133.91 |
| Hepatic function panel | CPT | 80076 | 13 | $180 | $8.99 | $3.84 | $16.34 | $114.78 |
| Urinalysis non-automated | CPT | 81002 | 13 | $43 | $3.83 | $1.64 | $6.93 | $27.42 |
| Urinalysis automated | CPT | 81003 | 13 | $77 | $2.48 | $1.06 | $4.48 | $49.1 |
| Glucose quantitative | CPT | 82947 | 13 | $46 | $4.32 | $1.85 | $5.27 | $29.33 |
| Hemoglobin A1c | CPT | 83036 | 13 | $115 | $10.68 | $4.56 | $18.91 | $73.33 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 13 | $275 | $18.48 | $7.9 | $33.6 | $175.36 |
| Complete blood count with automated differential | CPT | 85025 | 13 | $146 | $8.55 | $3.65 | $15.46 | $93.1 |
| Complete blood count without differential | CPT | 85027 | 13 | $102 | $7.12 | $3.04 | $12.88 | $65.04 |
| Urine culture bacterial | CPT | 87086 | 13 | $130 | $8.88 | $3.79 | $16.06 | $82.9 |
| Urine culture identification | CPT | 87088 | 13 | $78 | $8.9 | $3.8 | $12.83 | $49.74 |
| Tissue exam by pathologist level IV | CPT | 88305 | 13 | $429 | $80.52 | $23.57 | $104 | $481 |
| maternity |
| Fetal non-stress test | CPT | 59025 | 13 | $1,064 | $5,855 | $25.35 | $678.51 | $4,118 |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 8 | — | $5,855 | $15.02 | $63.28 | $4,118 |
| Vaginal delivery only | CPT | 59409 | 13 | — | $5,855 | $15.02 | $3,474.84 | $14,541 |
| Vaginal delivery with postpartum | CPT | 59410 | 7 | — | $5,855 | $15.02 | $61.4 | $2,612 |
| Routine obstetric care with C-section | CPT | 59510 | 8 | — | $5,855 | $15.02 | $63.28 | $4,118 |
| C-section delivery only | CPT | 59514 | 7 | — | $5,855 | $15.02 | $61.4 | $4,118 |
| C-section with postpartum | CPT | 59515 | 8 | — | $5,855 | $15.02 | $63.28 | $2,612 |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 8 | $391 | $73.39 | $38.57 | $241.97 | $380.75 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 8 | $578 | $108.49 | $59.34 | $357.7 | $562.85 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 8 | $697 | $130.82 | $88.72 | $431.34 | $678.73 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 8 | $809 | $151.84 | $116.9 | $500.65 | $787.8 |
| Office visit, established patient, 5 min | CPT | 99211 | 8 | $305 | $57.24 | $12.1 | $188.75 | $297 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 8 | $465 | $87.28 | $30.25 | $287.77 | $452.81 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 8 | $513 | $96.29 | $48.38 | $317.47 | $499.55 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 8 | $564 | $105.86 | $68.14 | $349.03 | $549.22 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 8 | $665 | $124.82 | $99.88 | $411.54 | $647.57 |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 13 | — | $5,855 | $15.02 | $1,045.13 | $4,523 |
| Upper GI endoscopy with biopsy | CPT | 43239 | 13 | — | $5,855 | $15.02 | $1,673.82 | $4,523 |
| Sigmoidoscopy diagnostic | CPT | 45330 | 13 | — | $5,855 | $15.02 | $1,016.32 | $4,169.49 |
| Sigmoidoscopy with biopsy | CPT | 45331 | 13 | — | $5,855 | $15.02 | $1,016.32 | $4,169.49 |
| Colonoscopy diagnostic | CPT | 45378 | 13 | — | $5,855 | $15.02 | $1,673.82 | $4,523 |
| Colonoscopy with biopsy | CPT | 45380 | 13 | — | $5,855 | $15.02 | $1,673.82 | $5,392.23 |
| Colonoscopy with polyp removal | CPT | 45385 | 13 | — | $5,855 | $15.02 | $1,673.82 | $5,392.23 |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 13 | — | $5,855 | $15.02 | $20,098 | $84,103 |
| PCI w drug-eluting stent w MCC | MS-DRG | 246 | 2 | — | — | $25,837 | $34,027 | $42,216 |
| PCI w drug-eluting stent w/o MCC | MS-DRG | 247 | 2 | — | — | $16,570 | $22,126 | $27,682 |
| Hip hemiarthroplasty | CPT | 27125 | 8 | — | $5,855 | $15.02 | $1,136.9 | $26,500 |
| Total hip replacement | CPT | 27130 | 13 | — | $5,855 | $15.02 | $14,062 | $58,843 |
| Total knee replacement | CPT | 27447 | 13 | — | $5,855 | $15.02 | $14,062 | $58,843 |
| Knee revision arthroplasty single component | CPT | 27486 | 8 | — | $5,855 | $15.02 | $1,205.51 | $26,500 |
| Knee revision arthroplasty all components | CPT | 27487 | 8 | — | $5,855 | $15.02 | $1,293.08 | $26,500 |
| Shoulder arthroscopy with decompression | CPT | 29826 | 8 | — | $5,855 | $15.02 | $802.61 | $24,027 |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 13 | — | $5,855 | $15.02 | $7,807.24 | $32,670 |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 13 | — | $5,855 | $15.02 | $3,545.97 | $24,027 |
| ACL reconstruction | CPT | 29888 | 13 | — | $5,855 | $15.02 | $7,807.24 | $32,670 |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 13 | — | $2,726 | $60 | $61,521 | $122,553 |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 13 | — | $2,726 | $60 | $31,582 | $63,085 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 13 | — | $2,726 | $60 | $21,292 | $44,064 |
| CABG single arterial graft | CPT | 33533 | 8 | — | $5,855 | $15.02 | $90.66 | $3,236 |
| CABG 2 arterial grafts | CPT | 33534 | 8 | — | $5,855 | $15.02 | $90.66 | $3,236 |
| CABG 3 arterial grafts | CPT | 33535 | 8 | — | $5,855 | $15.02 | $90.66 | $3,236 |
| CABG 4+ arterial grafts | CPT | 33536 | 8 | — | $5,855 | $15.02 | $90.66 | $3,236 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 13 | — | $2,726 | $60 | $21,117 | $44,261 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 13 | — | $2,726 | $60 | $16,455 | $35,165 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 13 | — | $2,726 | $60 | $43,659 | $94,199 |
| Open appendectomy | CPT | 44950 | 13 | — | $5,855 | $15.02 | $5,390 | $28,536 |
| Laparoscopic appendectomy | CPT | 44970 | 13 | — | $5,855 | $15.02 | $6,376.26 | $26,682 |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 2 | — | — | $50,935 | $91,019 | $101,547 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 2 | — | — | $32,209 | $52,549 | $56,006 |
| Major joint replacement w MCC | MS-DRG | 469 | 13 | — | $2,726 | $60 | $42,482 | $87,238 |
| Major joint replacement w/o MCC | MS-DRG | 470 | 13 | — | $2,726 | $60 | $24,608 | $47,391 |
| Laparoscopic cholecystectomy | CPT | 47562 | 13 | — | $5,855 | $15.02 | $6,376.26 | $26,682 |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 13 | — | $5,855 | $15.02 | $6,376.26 | $26,682 |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 13 | — | $2,726 | $60 | $38,141 | $78,492 |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 13 | — | $2,726 | $60 | $25,985 | $55,377 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 13 | — | $2,726 | $60 | $20,592 | $42,339 |
| Lap inguinal hernia repair | CPT | 49650 | 13 | — | $5,855 | $15.02 | $6,376.26 | $26,682 |
| Total abdominal hysterectomy | CPT | 58150 | 8 | — | $5,855 | $15.02 | $90.66 | $6,341 |
| Vaginal hysterectomy | CPT | 58260 | 13 | — | $5,855 | $15.02 | $5,394.95 | $22,576 |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 13 | — | $5,855 | $15.02 | $6,376.26 | $26,682 |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 13 | — | $5,855 | $15.02 | $7,987 | $47,613 |
| Lap salpingo-oophorectomy | CPT | 58661 | 13 | — | $5,855 | $15.02 | $6,376.26 | $26,682 |
| OR procedure for obesity w MCC | MS-DRG | 619 | 13 | — | $2,726 | $60 | $26,150 | $53,704 |
| OR procedure for obesity w CC | MS-DRG | 620 | 13 | — | $2,726 | $60 | $20,134 | $43,329 |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 13 | — | $2,726 | $60 | $19,864 | $43,329 |
| Complex cataract surgery | CPT | 66982 | 13 | — | $5,855 | $15.02 | $2,612 | $10,430 |
| Cataract surgery with lens implant | CPT | 66984 | 13 | — | $5,855 | $15.02 | $2,612 | $10,430 |
| Intravitreal injection | CPT | 67028 | 13 | — | $5,855 | $15.02 | $380.41 | $3,236 |
| Vitrectomy mechanical | CPT | 67042 | 13 | — | $5,855 | $15.02 | $4,440.47 | $18,398 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 13 | — | $2,726 | $60 | $13,907 | $31,992 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 13 | — | $2,726 | $60 | $22,857 | $52,150 |
| PCI single major coronary artery | CPT | 92920 | 14 | $15,906 | — | $15.02 | $6,231.08 | $50,824 |
| PCI with drug-eluting stent | CPT | 92928 | 14 | $24,712 | — | $15.02 | $12,394 | $51,863 |
| PCI bypass graft | CPT | 92937 | 14 | $17,872 | — | $15.02 | $12,394 | $51,863 |
| Left heart catheterization | CPT | 93452 | 13 | $14,112 | $2,648.82 | $460.23 | $6,308 | $14,710 |
| Coronary angiography with cath | CPT | 93455 | 13 | $21,408 | $4,018.28 | $516.71 | $6,422.4 | $16,521 |
| Coronary angiography with bypass cath | CPT | 93458 | 13 | $21,894 | $4,109.5 | $533.38 | $6,568.2 | $16,896 |