| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $1,475 | $352.38 | — | — | — |
| Psychiatric eval with medical services | CPT | 90792 | 0 | $1,536 | $366.95 | — | — | — |
| Psychotherapy 30 minutes | CPT | 90832 | 0 | $1,243 | $296.95 | — | — | — |
| Psychotherapy 45 minutes | CPT | 90834 | 0 | $1,308 | $312.48 | — | — | — |
| Psychotherapy 60 minutes | CPT | 90837 | 0 | $1,433 | $342.34 | — | — | — |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 0 | $1,420 | $339.24 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $572 | $136.65 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,029 | $245.83 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $1,800 | $430.02 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $2,768 | $661.28 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $3,985 | $952.02 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $5,477 | $1,308.46 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $532 | $127.09 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $890 | $212.62 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $890 | $212.62 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $890 | $212.62 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $1,209 | $288.83 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $1,786 | $426.68 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $1,786 | $426.68 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $440 | $105.12 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $440 | $105.12 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $440 | $105.12 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $532 | $127.09 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $890 | $212.62 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $890 | $212.62 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $1,209 | $288.83 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $3,950 | $943.66 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $1,786 | $426.68 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $532 | $127.09 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $532 | $127.09 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $532 | $127.09 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $532 | $127.09 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $1,209 | $288.83 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $1,209 | $288.83 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $1,209 | $288.83 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $1,786 | $426.68 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $1,786 | $426.68 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $1,786 | $426.68 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $532 | $127.09 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $890 | $212.62 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $440 | $105.12 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $440 | $105.12 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $440 | $105.12 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $1,209 | $288.83 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $1,786 | $426.68 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $440 | $105.12 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $440 | $105.12 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $1,209 | $288.83 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $1,786 | $426.68 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $532 | $127.09 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $890 | $212.62 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $890 | $212.62 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $1,209 | $288.83 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $1,786 | $426.68 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $1,786 | $426.68 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $1,209 | $288.83 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $1,786 | $426.68 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $532 | $127.09 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $532 | $127.09 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $532 | $127.09 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $532 | $127.09 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $532 | $127.09 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,209 | $288.83 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $532 | $127.09 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $532 | $127.09 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $532 | $127.09 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $513 | $122.56 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $653 | $156 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $540 | $129.01 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $386 | $92.22 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $5,135 | $1,226.75 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $1,571 | $375.31 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $5,135 | $1,226.75 | — | — | — |
| inpatient |
| Respiratory infections & inflammations w MCC | MS-DRG | 177 | 0 | — | — | — | — | — |
| COPD w MCC | MS-DRG | 190 | 0 | — | — | — | — | — |
| COPD w CC | MS-DRG | 191 | 0 | — | — | — | — | — |
| COPD w/o CC/MCC | MS-DRG | 192 | 0 | — | — | — | — | — |
| Simple pneumonia & pleurisy w CC | MS-DRG | 194 | 0 | — | — | — | — | — |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG | 195 | 0 | — | — | — | — | — |
| AMI discharged alive w MCC | MS-DRG | 280 | 0 | — | — | — | — | — |
| AMI discharged alive w CC | MS-DRG | 281 | 0 | — | — | — | — | — |
| AMI discharged alive w/o CC/MCC | MS-DRG | 282 | 0 | — | — | — | — | — |
| Heart failure & shock w MCC | MS-DRG | 291 | 0 | — | — | — | — | — |
| Heart failure & shock w CC | MS-DRG | 292 | 0 | — | — | — | — | — |
| Heart failure & shock w/o CC/MCC | MS-DRG | 293 | 0 | — | — | — | — | — |
| Cardiac arrhythmia w MCC | MS-DRG | 308 | 0 | — | — | — | — | — |
| Cardiac arrhythmia w CC | MS-DRG | 309 | 0 | — | — | — | — | — |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG | 310 | 0 | — | — | — | — | — |
| GI hemorrhage w CC | MS-DRG | 378 | 0 | — | — | — | — | — |
| GI hemorrhage w/o CC/MCC | MS-DRG | 379 | 0 | — | — | — | — | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG | 392 | 0 | — | — | — | — | — |
| Fractures of femur w/o MCC | MS-DRG | 533 | 0 | — | — | — | — | — |
| Kidney/UTI w MCC | MS-DRG | 689 | 0 | — | — | — | — | — |
| Kidney/UTI w/o MCC | MS-DRG | 690 | 0 | — | — | — | — | — |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG | 871 | 0 | — | — | — | — | — |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG | 872 | 0 | — | — | — | — | — |
| Initial hospital care, low complexity | CPT | 99221 | 0 | $236 | $56.38 | — | — | — |
| Initial hospital care, moderate complexity | CPT | 99222 | 0 | $372 | $88.87 | — | — | — |
| Initial hospital care, high complexity | CPT | 99223 | 0 | $493 | $117.78 | — | — | — |
| Hospital discharge, <30 min | CPT | 99238 | 0 | $230 | $54.95 | — | — | — |
| Hospital discharge, >30 min | CPT | 99239 | 0 | $325 | $77.64 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $55 | $13.14 | — | — | — |
| General health panel | CPT | 80050 | 0 | $383 | $91.5 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $46 | $10.99 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $69 | $16.48 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $87 | $20.78 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $56 | $13.38 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $53 | $12.66 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $23 | $5.49 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $15 | $3.58 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $26 | $6.21 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $63 | $15.05 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $109 | $26.04 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $51 | $12.18 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $42 | $10.03 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $52 | $12.42 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $53 | $12.66 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $347 | $82.9 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $1,308 | $312.48 | — | — | — |
| Routine obstetric care including vaginal delivery | CPT | 59400 | 0 | $20,667 | $4,937.35 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $20,667 | $4,937.35 | — | — | — |
| Vaginal delivery with postpartum | CPT | 59410 | 0 | $20,667 | $4,937.35 | — | — | — |
| Routine obstetric care with C-section | CPT | 59510 | 0 | $20,667 | $4,937.35 | — | — | — |
| C-section delivery only | CPT | 59514 | 0 | $20,667 | $4,937.35 | — | — | — |
| C-section with postpartum | CPT | 59515 | 0 | $20,667 | $4,937.35 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $250 | $59.73 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $349 | $83.38 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $495 | $118.26 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $632 | $150.98 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $140 | $33.45 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $216 | $51.6 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $303 | $72.39 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $392 | $93.65 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $526 | $125.66 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $6,094 | $1,455.86 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $6,094 | $1,455.86 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $5,926 | $1,415.72 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $5,926 | $1,415.72 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $5,926 | $1,415.72 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $7,664 | $1,830.93 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $7,664 | $1,830.93 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $119,535 | $28,557 | — | — | — |
| Hip hemiarthroplasty | CPT | 27125 | 0 | $36,060 | $8,614.73 | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $83,634 | $19,980 | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $83,634 | $19,980 | — | — | — |
| Knee revision arthroplasty single component | CPT | 27486 | 0 | $36,060 | $8,614.73 | — | — | — |
| Knee revision arthroplasty all components | CPT | 27487 | 0 | $36,060 | $8,614.73 | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $3,863 | $922.87 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $46,434 | $11,093 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $21,090 | $5,038.4 | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $46,434 | $11,093 | — | — | — |
| Major small/large bowel procedures w MCC | MS-DRG | 329 | 0 | — | — | — | — | — |
| Major small/large bowel procedures w CC | MS-DRG | 330 | 0 | — | — | — | — | — |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG | 331 | 0 | — | — | — | — | — |
| CABG single arterial graft | CPT | 33533 | 0 | $33,477 | $7,997.66 | — | — | — |
| CABG 2 arterial grafts | CPT | 33534 | 0 | $20,553 | $4,910.11 | — | — | — |
| CABG 3 arterial grafts | CPT | 33535 | 0 | $22,844 | $5,457.43 | — | — | — |
| CABG 4+ arterial grafts | CPT | 33536 | 0 | $36,948 | $8,826.88 | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG | 418 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG | 419 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG | 420 | 0 | — | — | — | — | — |
| Open appendectomy | CPT | 44950 | 0 | $40,558 | $9,689.31 | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $37,923 | $9,059.8 | — | — | — |
| Major joint replacement w MCC | MS-DRG | 469 | 0 | — | — | — | — | — |
| Major joint replacement w/o MCC | MS-DRG | 470 | 0 | — | — | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $37,923 | $9,059.8 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $37,923 | $9,059.8 | — | — | — |
| Hip & femur procedures except major joint w MCC | MS-DRG | 480 | 0 | — | — | — | — | — |
| Hip & femur procedures except major joint w CC | MS-DRG | 481 | 0 | — | — | — | — | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG | 482 | 0 | — | — | — | — | — |
| Lap inguinal hernia repair | CPT | 49650 | 0 | $37,923 | $9,059.8 | — | — | — |
| Total abdominal hysterectomy | CPT | 58150 | 0 | $9,709 | $2,319.48 | — | — | — |
| Vaginal hysterectomy | CPT | 58260 | 0 | $32,087 | $7,665.58 | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | $37,923 | $9,059.8 | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $67,673 | $16,167 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $37,923 | $9,059.8 | — | — | — |
| OR procedure for obesity w MCC | MS-DRG | 619 | 0 | — | — | — | — | — |
| OR procedure for obesity w CC | MS-DRG | 620 | 0 | — | — | — | — | — |
| OR procedure for obesity w/o CC/MCC | MS-DRG | 621 | 0 | — | — | — | — | — |
| Complex cataract surgery | CPT | 66982 | 0 | $14,825 | $3,541.69 | — | — | — |
| Cataract surgery with lens implant | CPT | 66984 | 0 | $14,825 | $3,541.69 | — | — | — |
| Intravitreal injection | CPT | 67028 | 0 | $2,156 | $515.07 | — | — | — |
| Vitrectomy mechanical | CPT | 67042 | 0 | $26,149 | $6,247 | — | — | — |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 0 | — | — | — | — | — |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 0 | — | — | — | — | — |
| PCI single major coronary artery | CPT | 92920 | 0 | $37,060 | $8,853.63 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $73,714 | $17,610 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $73,714 | $17,610 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $20,907 | $4,994.68 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $20,907 | $4,994.68 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $20,907 | $4,994.68 | — | — | — |
