| behavioral |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $502 | $376.5 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $363 | $272.25 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $773 | $579.75 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $1,163 | $872.25 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $1,829 | $1,371.75 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $2,622 | $1,966.5 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $3,363 | $2,522.25 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $1,399 | $1,049.25 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $2,637 | $1,977.75 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $2,637 | $1,977.75 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $2,274 | $1,705.5 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $2,024 | $1,518 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $5,321 | $3,990.75 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $4,030 | $3,022.5 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $405 | $303.75 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $408 | $306 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $512 | $384 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $1,399 | $1,049.25 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $2,274 | $1,705.5 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $2,228 | $1,671 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $3,886 | $2,914.5 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $5,149 | $3,861.75 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $6,230 | $4,672.5 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $609 | $456.75 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $1,399 | $1,049.25 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $1,399 | $1,049.25 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $1,399 | $1,049.25 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $2,459 | $1,844.25 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $2,279 | $1,709.25 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $2,024 | $1,518 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $5,149 | $3,861.75 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $3,474 | $2,605.5 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $4,030 | $3,022.5 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $1,399 | $1,049.25 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $2,637 | $1,977.75 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $442 | $331.5 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $434 | $325.5 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $454 | $340.5 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $2,347 | $1,760.25 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $6,230 | $4,672.5 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $527 | $395.25 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $527 | $395.25 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $2,459 | $1,844.25 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $6,909 | $5,181.75 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $1,399 | $1,049.25 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $2,274 | $1,705.5 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $2,274 | $1,705.5 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $3,226 | $2,419.5 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $5,525 | $4,143.75 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $5,525 | $4,143.75 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $2,436 | $1,827 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $3,316 | $2,487 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,218 | $913.5 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,194 | $895.5 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $974 | $730.5 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $1,207 | $905.25 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,207 | $905.25 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $1,194 | $895.5 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $1,218 | $913.5 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,218 | $913.5 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $397 | $297.75 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $499 | $374.25 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $150 | $112.5 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $351 | $263.25 | — | — | — |
| EKG interpretation only | CPT | 93010 | 0 | $146 | $109.5 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $3,013 | $2,259.75 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $751 | $563.25 | — | — | — |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 0 | $31,840 | $23,880 | — | — | — |
| COPD w MCC | MS-DRG | 190 | 0 | $21,000 | $15,750 | — | — | — |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 0 | $28,468 | $21,351 | — | — | — |
| AMI discharged alive w MCC | MS-DRG | 280 | 0 | $20,908 | $15,681 | — | — | — |
| AMI discharged alive w CC | MS-DRG | 281 | 0 | $6,554.81 | $4,916.11 | — | — | — |
| Heart failure & shock w MCC | MS-DRG | 291 | 0 | $25,904 | $19,428 | — | — | — |
| Heart failure & shock w CC | MS-DRG | 292 | 0 | $32,976 | $24,732 | — | — | — |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 0 | $35,894 | $26,920 | — | — | — |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 0 | $16,633 | $12,475 | — | — | — |
| GI hemorrhage w CC | MS-DRG | 378 | 0 | $21,837 | $16,378 | — | — | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 0 | $19,508 | $14,631 | — | — | — |
| Kidney/UTI w MCC | MS-DRG | 689 | 0 | $32,117 | $24,088 | — | — | — |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 0 | $22,448 | $16,836 | — | — | — |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 0 | $38,301 | $28,726 | — | — | — |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 0 | $28,902 | $21,676 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $47 | $35.25 | — | — | — |
| General health panel | CPT | 80050 | 0 | $304 | $228 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $38 | $28.5 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $112 | $84 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $72 | $54 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $46 | $34.5 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $45 | $33.75 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $22 | $16.5 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $10 | $7.5 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $24 | $18 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $54 | $40.5 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $89 | $66.75 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $110 | $82.5 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $65 | $48.75 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $45 | $33.75 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $57 | $42.75 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $304 | $228 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $4,076 | $3,057 | — | — | — |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 0 | $13,705 | $10,279 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $13,705 | $10,279 | — | — | — |
| Vaginal delivery with postpartum | CPT | 59410 | 0 | $13,705 | $10,279 | — | — | — |
| Routine obstetric care with C-section | CPT | 59510 | 0 | $25,412 | $19,059 | — | — | — |
| C-section delivery only | CPT | 59514 | 0 | $25,412 | $19,059 | — | — | — |
| C-section with postpartum | CPT | 59515 | 0 | $25,412 | $19,059 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $323 | $242.25 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $391 | $293.25 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $432 | $324 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $420 | $315 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $181 | $135.75 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $219 | $164.25 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $288 | $216 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $403 | $302.25 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $490 | $367.5 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $26,318 | $19,738 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $26,923 | $20,192 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $8,400.48 | $6,300.36 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $9,310.1 | $6,982.58 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $4,763.8 | $3,572.85 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $27,473 | $20,605 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $26,477 | $19,858 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $58,373 | $43,780 | — | — | — |
| Hip hemiarthroplasty | CPT | 27125 | 0 | $46,050 | $34,537 | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $48,078 | $36,058 | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $74,762 | $56,072 | — | — | — |
| Knee revision arthroplasty single component | CPT | 27486 | 0 | $68,114 | $51,086 | — | — | — |
| Knee revision arthroplasty all components | CPT | 27487 | 0 | $74,098 | $55,573 | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $30,485 | $22,863 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $33,172 | $24,879 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $12,129 | $9,096.48 | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $37,680 | $28,260 | — | — | — |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 0 | $67,236 | $50,427 | — | — | — |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 0 | $75,963 | $56,973 | — | — | — |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 0 | $47,944 | $35,958 | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 0 | $45,857 | $34,393 | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 0 | $28,461 | $21,346 | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 0 | $22,193 | $16,645 | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $36,595 | $27,447 | — | — | — |
| Major joint replacement w MCC | MS-DRG | 469 | 0 | $110,215 | $82,661 | — | — | — |
| Major joint replacement w/o MCC | MS-DRG | 470 | 0 | $53,492 | $40,119 | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $42,136 | $31,602 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $32,498 | $24,374 | — | — | — |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 0 | $45,674 | $34,255 | — | — | — |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 0 | $47,158 | $35,368 | — | — | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 0 | $28,200 | $21,150 | — | — | — |
| Lap inguinal hernia repair | CPT | 49650 | 0 | $27,339 | $20,504 | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | $27,732 | $20,799 | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | $25,497 | $19,123 | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $29,090 | $21,818 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $20,360 | $15,270 | — | — | — |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 0 | $23,449 | $17,587 | — | — | — |
