| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $745 | $745 | — | — | — |
| Psychiatric eval with medical services | CPT | 90792 | 0 | $704 | $704 | — | — | — |
| Psychotherapy 30 minutes | CPT | 90832 | 0 | $525 | $525 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $642 | $642 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,562 | $1,562 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $2,061 | $2,061 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $3,297 | $3,297 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $4,953 | $4,953 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $6,097 | $6,097 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $4,165 | $4,165 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $5,653 | $5,653 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $6,751 | $6,751 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $5,653 | $5,653 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $6,802 | $6,802 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $6,820 | $6,820 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $10,783 | $10,783 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $670 | $670 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $863 | $863 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $1,202 | $1,202 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $4,165 | $4,165 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $5,653 | $5,653 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $6,964 | $6,964 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $4,954 | $4,954 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $7,093 | $7,093 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $9,380 | $9,380 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $1,202 | $1,202 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $4,165 | $4,165 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $6,236 | $6,236 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $4,165 | $4,165 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $7,310 | $7,310 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $7,310 | $7,310 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $6,802 | $6,802 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $8,858 | $8,858 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $11,736 | $11,736 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $10,822 | $10,822 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $4,165 | $4,165 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $5,737 | $5,737 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $825 | $825 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $825 | $825 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $676 | $676 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $4,467 | $4,467 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $18,063 | $18,063 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $845 | $845 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $919 | $919 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $6,567 | $6,567 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $7,129 | $7,129 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $4,165 | $4,165 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $5,653 | $5,653 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $6,751 | $6,751 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $8,329 | $8,329 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $11,304 | $11,304 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $13,954 | $13,954 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $5,202 | $5,202 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $7,129 | $7,129 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $3,317 | $3,317 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,895 | $1,895 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $2,843 | $2,843 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $1,092 | $1,092 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $1,884 | $1,884 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $1,685 | $1,685 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $1,792 | $1,792 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $2,575 | $2,575 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $1,938 | $1,938 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $1,057 | $1,057 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,057 | $1,057 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,057 | $1,057 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $794 | $794 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $7,909 | $7,909 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $5,206 | $5,206 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $9,026 | $9,026 | — | — | — |
| 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 | — | — | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $287 | $287 | — | — | — |
| General health panel | CPT | 80050 | 0 | $1,071 | $1,071 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $237 | $237 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $403 | $403 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $527 | $527 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $108 | $108 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $277 | $277 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $34 | $34 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $119 | $119 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $384 | $384 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $320 | $320 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $594 | $594 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $281 | $281 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $251 | $251 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $238 | $238 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $201 | $201 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $2,402 | $2,402 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $1,165 | $1,165 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $856 | $856 | — | — | — |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 0 | $405 | $405 | — | — | — |
| Office visit, new patient, 45-59 min | CPT | 99204 | 0 | $965 | $965 | — | — | — |
| Office visit, new patient, 60-74 min | CPT | 99205 | 0 | $1,232 | $1,232 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $1,359 | $1,359 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $557 | $557 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $777 | $777 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $965 | $965 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $1,232 | $1,232 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $4,027 | $4,027 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $4,273 | $4,273 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $3,425 | $3,425 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $4,131 | $4,131 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $4,779 | $4,779 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $5,689 | $5,689 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $6,402 | $6,402 | — | — | — |
| surgery |
| 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 | $450 | $450 | — | — | — |
| 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 | $48,161 | $48,161 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $64,309 | $64,309 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $141,884 | $141,884 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $17,290 | $17,290 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $31,923 | $31,923 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $46,884 | $46,884 | — | — | — |
