| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $783 | $783 | — | — | — |
| Psychiatric eval with medical services | CPT | 90792 | 0 | $2,400 | $2,400 | — | — | — |
| Psychotherapy 30 minutes | CPT | 90832 | 0 | $552 | $552 | — | — | — |
| Psychotherapy 45 minutes | CPT | 90834 | 0 | $161 | $161 | — | — | — |
| Psychotherapy 60 minutes | CPT | 90837 | 0 | $189 | $189 | — | — | — |
| Crisis psychotherapy 60 minutes | CPT | 90839 | 0 | $126 | $126 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $1,314 | $1,314 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,473 | $1,473 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $2,232 | $2,232 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $3,489 | $3,489 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $6,331 | $6,331 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $10,688 | $10,688 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $3,957 | $3,957 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $4,855 | $4,855 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $6,026 | $6,026 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $5,123 | $5,123 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $9,957 | $9,957 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $11,605 | $11,605 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $19,502 | $19,502 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $471 | $471 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $797 | $797 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $615 | $615 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $4,995 | $4,995 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $6,041 | $6,041 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $7,583 | $7,583 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $10,192 | $10,192 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $11,872 | $11,872 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $19,727 | $19,727 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $588 | $588 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $4,995 | $4,995 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $4,995 | $4,995 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $4,995 | $4,995 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $9,578 | $9,578 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $10,369 | $10,369 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $10,369 | $10,369 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $11,605 | $11,605 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $19,434 | $19,434 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $19,434 | $19,434 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $4,918 | $4,918 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $5,816 | $5,816 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $480 | $480 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $480 | $480 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $454 | $454 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $9,618 | $9,618 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $18,967 | $18,967 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $435 | $435 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $467 | $467 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $9,744 | $9,744 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $18,958 | $18,958 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $4,765 | $4,765 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $6,048 | $6,048 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $7,739 | $7,739 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $3,778 | $3,778 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $7,194 | $7,194 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $9,516 | $9,516 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $9,437 | $9,437 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $19,294 | $19,294 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $1,819 | $1,819 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $1,684 | $1,684 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $1,802 | $1,802 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $1,811 | $1,811 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $3,033 | $3,033 | — | — | — |
| Obstetric ultrasound with fetal anatomy | CPT | 76811 | 0 | $3,029 | $3,029 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $2,543 | $2,543 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $2,543 | $2,543 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $2,305 | $2,305 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $2,032 | $2,032 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $2,448 | $2,448 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $2,388 | $2,388 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $898 | $898 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $10,616 | $10,616 | — | — | — |
| Stress echocardiogram | CPT | 93350 | 0 | $5,739 | $5,739 | — | — | — |
| 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 | $263 | $263 | — | — | — |
| General health panel | CPT | 80050 | 0 | $1,125 | $1,125 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $218 | $218 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $368 | $368 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $480 | $480 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $102 | $102 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $254 | $254 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $179 | $179 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $125 | $125 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $404 | $404 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $174 | $174 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $594 | $594 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $273 | $273 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $245 | $245 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $286 | $286 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $240 | $240 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $1,775 | $1,775 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $1,585 | $1,585 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $17,401 | $17,401 | — | — | — |
| Vaginal delivery with postpartum | CPT | 59410 | 0 | $13,985 | $13,985 | — | — | — |
| C-section delivery only | CPT | 59514 | 0 | $17,316 | $17,316 | — | — | — |
| C-section with postpartum | CPT | 59515 | 0 | $17,316 | $17,316 | — | — | — |
| office |
| Office visit, new patient, 15-29 min | CPT | 99202 | 0 | $767 | $767 | — | — | — |
| Office visit, established patient, 5 min | CPT | 99211 | 0 | $468 | $468 | — | — | — |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $305 | $305 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $366 | $366 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $518 | $518 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $1,294 | $1,294 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $3,897 | $3,897 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $4,134 | $4,134 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $3,010 | $3,010 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $3,315 | $3,315 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $4,927 | $4,927 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $4,399 | $4,399 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $6,195 | $6,195 | — | — | — |
| 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 | — | — | — | — | — |
| Open umbilical hernia repair | CPT | 49560 | 0 | $12,502 | $12,502 | — | — | — |
| Umbilical hernia repair age 5+ | CPT | 49585 | 0 | $9,887 | $9,887 | — | — | — |
| 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 | $46,950 | $46,950 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $127,709 | $127,709 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $127,709 | $127,709 | — | — | — |
| Left heart catheterization | CPT | 93452 | 0 | $48,121 | $48,121 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $55,886 | $55,886 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $57,407 | $57,407 | — | — | — |
