| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $918.9 | $321.62 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $1,632.97 | $571.54 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $2,729.81 | $955.43 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $4,455.67 | $1,559.48 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $8,622.55 | $3,017.89 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $22,739 | $7,958.74 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $8,372.77 | $2,930.47 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $9,410.26 | $3,293.59 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $10,750 | $3,762.48 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $9,351.91 | $3,273.17 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $11,834 | $4,141.73 | — | — | — |
| MRI brain with contrast | CPT | 70552 | 0 | $15,041 | $5,264.43 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $16,750 | $5,862.35 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $998.35 | $349.42 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $1,268.48 | $443.97 | — | — | — |
| Chest X-ray 3 views | CPT | 71047 | 0 | $1,566.71 | $548.35 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $9,149.04 | $3,202.16 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $9,750.68 | $3,412.74 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $12,223 | $4,278.12 | — | — | — |
| MRI chest without contrast | CPT | 71550 | 0 | $13,366 | $4,678.14 | — | — | — |
| MRI chest with contrast | CPT | 71551 | 0 | $5,741.49 | $2,009.52 | — | — | — |
| MRI chest with and without contrast | CPT | 71552 | 0 | $13,302 | $4,655.63 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $1,193.11 | $417.59 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $8,779.51 | $3,072.83 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $8,779.51 | $3,072.83 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $9,351.91 | $3,273.17 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $13,302 | $4,655.63 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $13,302 | $4,655.63 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $13,302 | $4,655.63 | — | — | — |
| MRI lumbar spine with and without contrast | CPT | 72149 | 0 | $15,041 | $5,264.43 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $16,750 | $5,862.35 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $16,750 | $5,862.35 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $8,779.51 | $3,072.83 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $9,351.91 | $3,273.17 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $2,385.2 | $834.82 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $2,184.33 | $764.52 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $1,956.34 | $684.72 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $12,812 | $4,484.08 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $12,781 | $4,473.21 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $2,184.33 | $764.52 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $2,076.87 | $726.9 | — | — | — |
| MRI lower extremity joint without contrast | CPT | 73721 | 0 | $12,812 | $4,484.08 | — | — | — |
| MRI lower extremity joint with and without contrast | CPT | 73723 | 0 | $12,812 | $4,484.08 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $9,336.86 | $3,267.9 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $9,984.61 | $3,494.61 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $11,855 | $4,149.1 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $18,116 | $6,340.6 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $19,336 | $6,767.68 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $24,079 | $8,427.57 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $13,302 | $4,655.63 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $13,788 | $4,825.74 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $3,006.92 | $1,052.42 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $2,679.42 | $937.8 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $2,718.68 | $951.54 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $2,860.26 | $1,001.09 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $2,860.26 | $1,001.09 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $2,015.62 | $705.47 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $2,398.24 | $839.38 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $2,028.67 | $710.03 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $1,243.26 | $435.14 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,543.4 | $540.19 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,108.51 | $387.98 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $4,583.81 | $1,100.11 | — | — | — |
| Transthoracic echocardiogram complete | CPT | 93306 | 0 | $6,561.81 | $2,296.63 | — | — | — |
| Transthoracic echocardiogram | CPT | 93307 | 0 | $4,250.05 | $1,487.52 | — | — | — |
| 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 | $495.08 | $173.28 | — | — | — |
| General health panel | CPT | 80050 | 0 | $1,856.93 | $649.93 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $435.91 | $152.57 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $870.75 | $304.76 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $628.69 | $220.04 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $522.27 | $182.79 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $605.61 | $211.96 | — | — | — |
| Urinalysis non-automated | CPT | 81002 | 0 | $171.35 | $59.97 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $167.7 | $58.7 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $120.44 | $42.15 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $409.73 | $143.41 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $702 | $245.7 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $282.15 | $98.75 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $494.09 | $172.93 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $582.55 | $203.89 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $1,291.55 | $452.04 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $1,165.29 | $407.85 | — | — | — |
| preventive |
| Upper GI endoscopy diagnostic | CPT | 43235 | 0 | $11,711 | $2,810.63 | — | — | — |
| Upper GI endoscopy with biopsy | CPT | 43239 | 0 | $14,095 | $3,382.68 | — | — | — |
| Sigmoidoscopy diagnostic | CPT | 45330 | 0 | $13,081 | $3,139.44 | — | — | — |
| Sigmoidoscopy with biopsy | CPT | 45331 | 0 | $10,264 | $2,463.34 | — | — | — |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $12,145 | $2,914.86 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $12,872 | $3,089.37 | — | — | — |
| Colonoscopy with polyp removal | CPT | 45385 | 0 | $14,057 | $3,373.8 | — | — | — |
| surgery |
| Total shoulder arthroplasty | CPT | 23472 | 0 | $299,217 | $71,812 | — | — | — |
| Total hip replacement | CPT | 27130 | 0 | $238,533 | $57,248 | — | — | — |
| Total knee replacement | CPT | 27447 | 0 | $226,145 | $54,275 | — | — | — |
| Knee revision arthroplasty all components | CPT | 27487 | 0 | $425,524 | $102,126 | — | — | — |
| Shoulder arthroscopy with decompression | CPT | 29826 | 0 | $140,329 | $33,679 | — | — | — |
| Shoulder arthroscopy with rotator cuff repair | CPT | 29827 | 0 | $139,334 | $33,440 | — | — | — |
| Knee arthroscopy with meniscectomy | CPT | 29881 | 0 | $59,108 | $14,186 | — | — | — |
| ACL reconstruction | CPT | 29888 | 0 | $192,521 | $46,205 | — | — | — |
| 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 | — | — | — | — | — |
| Laparoscopic appendectomy | CPT | 44970 | 0 | $84,553 | $20,293 | — | — | — |
| 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 | — | — | — | — | — |
| Laparoscopic cholecystectomy | CPT | 47562 | 0 | $67,770 | $16,265 | — | — | — |
| Lap cholecystectomy with cholangiography | CPT | 47563 | 0 | $99,477 | $23,874 | — | — | — |
| 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 | $90,789 | $21,789 | — | — | — |
| Vaginal hysterectomy | CPT | 58260 | 0 | $67,236 | $16,137 | — | — | — |
| Lap-assisted vaginal hysterectomy | CPT | 58550 | 0 | $125,973 | $30,234 | — | — | — |
| Lap-assisted vaginal hysterectomy >250g | CPT | 58552 | 0 | $129,225 | $31,014 | — | — | — |
| Lap salpingo-oophorectomy | CPT | 58661 | 0 | $67,108 | $16,106 | — | — | — |
| 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 | — | — | — | — | — |
| 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 | $19,524 | $6,833.5 | — | — | — |
| PCI bypass graft | CPT | 92937 | 0 | $46,489 | $16,271 | — | — | — |
| Coronary angiography with cath | CPT | 93455 | 0 | $14,084 | $4,929.39 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $28,561 | $9,996.47 | — | — | — |
