| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $474 | $118.5 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $365 | $91.25 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $969 | $242.25 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $1,521 | $380.25 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $2,492 | $623 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $2,971 | $742.75 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $3,694 | $923.5 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $3,018 | $754.5 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $3,752 | $938 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $4,263 | $1,065.75 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $4,201 | $1,050.25 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $5,537 | $1,384.25 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $7,101 | $1,775.25 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $8,645 | $2,161.25 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $474 | $118.5 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $689 | $172.25 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $729 | $182.25 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $3,634 | $908.5 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $4,609 | $1,152.25 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $5,400 | $1,350 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $3,447 | $861.75 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $3,992 | $998 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $6,001 | $1,500.25 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $715 | $178.75 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $3,042 | $760.5 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $3,285 | $821.25 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $3,274 | $818.5 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $5,662 | $1,415.5 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $5,893 | $1,473.25 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $6,244 | $1,561 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $7,426 | $1,856.5 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $8,575 | $2,143.75 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $9,328 | $2,332 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $3,603 | $900.75 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $4,414 | $1,103.5 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $621 | $155.25 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $525 | $131.25 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $567 | $141.75 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $5,460 | $1,365 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $8,713 | $2,178.25 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $497 | $124.25 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $566 | $141.5 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $5,500 | $1,375 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $7,774 | $1,943.5 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $3,729 | $932.25 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $4,643 | $1,160.75 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $5,282 | $1,320.5 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $4,598 | $1,149.5 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $6,175 | $1,543.75 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $6,885 | $1,721.25 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $5,608 | $1,402 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $8,158 | $2,039.5 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,883 | $470.75 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,190 | $297.5 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,940 | $485 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $892 | $223 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,196 | $299 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,258 | $314.5 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $945 | $236.25 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $1,383 | $345.75 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,285 | $321.25 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $342 | $85.5 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $441 | $110.25 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $640 | $160 | — | — | — |
| EKG complete | CPT | 93000 | 0 | $88 | $22 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $484 | $121 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $4,055 | $1,013.75 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $1,240 | $310 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $1,210 | $302.5 | — | — | — |
| 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 | $312 | $78 | — | — | — |
| Initial hospital care, moderate complexity | CPT | 99222 | 0 | $420 | $105 | — | — | — |
| Initial hospital care, high complexity | CPT | 99223 | 0 | $621 | $155.25 | — | — | — |
| Hospital discharge, <30 min | CPT | 99238 | 0 | $223 | $55.75 | — | — | — |
| Hospital discharge, >30 min | CPT | 99239 | 0 | $327 | $81.75 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $307 | $76.75 | — | — | — |
| General health panel | CPT | 80050 | 0 | $373 | $93.25 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $226 | $56.5 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $578 | $144.5 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $279 | $69.75 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $374 | $93.5 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $414 | $103.5 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $45 | $11.25 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $54 | $13.5 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $120 | $30 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $174 | $43.5 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $273 | $68.25 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $145 | $36.25 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $117 | $29.25 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $153 | $38.25 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $131 | $32.75 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $567 | $141.75 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $1,595 | $398.75 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $8,629 | $2,157.25 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $264 | $66 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $347 | $86.75 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $498 | $124.5 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $603 | $150.75 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $194 | $48.5 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $216 | $54 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $270 | $67.5 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $333 | $83.25 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $422 | $105.5 | — | — | — |
| preventive |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $2,430 | $607.5 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $2,537 | $634.25 | — | — | — |
| surgery |
| PCI w drug-eluting stent w MCC | MS-DRG | 246 | 0 | — | — | — | — | — |
| PCI w drug-eluting stent w/o MCC | MS-DRG | 247 | 0 | — | — | — | — | — |
| 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 | — | — | — | — | — |
| 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 | — | — | — | — | — |
| Spinal fusion (non-cervical) w MCC | MS-DRG | 459 | 0 | — | — | — | — | — |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG | 460 | 0 | — | — | — | — | — |
| Major joint replacement w MCC | MS-DRG | 469 | 0 | — | — | — | — | — |
| Major joint replacement w/o MCC | MS-DRG | 470 | 0 | — | — | — | — | — |
| 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 | — | — | — | — | — |
| 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 | — | — | — | — | — |
| Intravitreal injection | CPT | 67028 | 0 | $640 | $160 | — | — | — |
| Uterine & adnexa procedures w CC/MCC | MS-DRG | 743 | 0 | — | — | — | — | — |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG | 744 | 0 | — | — | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $21,290 | $5,322.5 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $15,583 | $3,895.75 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $24,386 | $6,096.5 | — | — | — |
