| behavioral |
| Psychoses | MS-DRG | 885 | 0 | — | — | — | — | — |
| Psychiatric diagnostic evaluation | CPT | 90791 | 0 | $409.58 | $409.58 | — | — | — |
| Psychiatric eval with medical services | CPT | 90792 | 0 | $688.72 | $688.72 | — | — | — |
| Psychotherapy 30 minutes | CPT | 90832 | 0 | $334.61 | $334.61 | — | — | — |
| Psychotherapy 45 minutes | CPT | 90834 | 0 | $412.56 | $412.56 | — | — | — |
| Psychotherapy 60 minutes | CPT | 90837 | 0 | $515.09 | $515.09 | — | — | — |
| emergency |
| ED visit level 1 | CPT | 99281 | 0 | $322.59 | $322.59 | — | — | — |
| ED visit level 2 | CPT | 99282 | 0 | $623.69 | $623.69 | — | — | — |
| ED visit level 3 | CPT | 99283 | 0 | $950.47 | $950.47 | — | — | — |
| ED visit level 4 | CPT | 99284 | 0 | $1,575.59 | $1,575.59 | — | — | — |
| ED visit level 5 | CPT | 99285 | 0 | $2,207.32 | $2,207.32 | — | — | — |
| Critical care, first hour | CPT | 99291 | 0 | $3,516.98 | $3,516.98 | — | — | — |
| imaging |
| CT head without contrast | CPT | 70450 | 0 | $3,772.76 | $3,772.76 | — | — | — |
| CT head with contrast | CPT | 70460 | 0 | $3,253.26 | $3,253.26 | — | — | — |
| CT head with and without contrast | CPT | 70470 | 0 | $6,090.55 | $6,090.55 | — | — | — |
| CT neck with contrast | CPT | 70491 | 0 | $4,453.88 | $4,453.88 | — | — | — |
| MRI brain without contrast | CPT | 70551 | 0 | $5,518.07 | $5,518.07 | — | — | — |
| MRI brain with and without contrast | CPT | 70553 | 0 | $11,573 | $11,573 | — | — | — |
| Chest X-ray single view | CPT | 71045 | 0 | $642.21 | $642.21 | — | — | — |
| Chest X-ray 2 views | CPT | 71046 | 0 | $1,501.28 | $1,501.28 | — | — | — |
| CT chest without contrast | CPT | 71250 | 0 | $4,208.58 | $4,208.58 | — | — | — |
| CT chest with contrast | CPT | 71260 | 0 | $5,634.44 | $5,634.44 | — | — | — |
| CT chest with and without contrast | CPT | 71270 | 0 | $6,297.6 | $6,297.6 | — | — | — |
| Lumbosacral spine X-ray | CPT | 72100 | 0 | $1,878.22 | $1,878.22 | — | — | — |
| CT cervical spine without contrast | CPT | 72125 | 0 | $4,208.58 | $4,208.58 | — | — | — |
| CT thoracic spine without contrast | CPT | 72128 | 0 | $3,924.8 | $3,924.8 | — | — | — |
| CT lumbar spine without contrast | CPT | 72131 | 0 | $4,208.58 | $4,208.58 | — | — | — |
| MRI cervical spine without contrast | CPT | 72141 | 0 | $7,973.94 | $7,973.94 | — | — | — |
| MRI thoracic spine without contrast | CPT | 72146 | 0 | $8,423.84 | $8,423.84 | — | — | — |
| MRI lumbar spine without contrast | CPT | 72148 | 0 | $8,845.03 | $8,845.03 | — | — | — |
| MRI cervical spine with and without contrast | CPT | 72156 | 0 | $5,457.95 | $5,457.95 | — | — | — |
| MRI lumbar spine with contrast | CPT | 72158 | 0 | $11,315 | $11,315 | — | — | — |
| CT pelvis without contrast | CPT | 72192 | 0 | $3,761.95 | $3,761.95 | — | — | — |
| CT pelvis with contrast | CPT | 72193 | 0 | $4,975.74 | $4,975.74 | — | — | — |
| Shoulder X-ray | CPT | 73030 | 0 | $2,070.83 | $2,070.83 | — | — | — |
| Humerus X-ray | CPT | 73060 | 0 | $1,203.05 | $1,203.05 | — | — | — |
| Hand X-ray 3 views | CPT | 73130 | 0 | $4,051.35 | $4,051.35 | — | — | — |
| MRI upper extremity joint without contrast | CPT | 73221 | 0 | $11,703 | $11,703 | — | — | — |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 0 | $11,452 | $11,452 | — | — | — |
| Knee X-ray 1-2 views | CPT | 73560 | 0 | $2,446.23 | $2,446.23 | — | — | — |
| Ankle X-ray 3 views | CPT | 73610 | 0 | $3,943.2 | $3,943.2 | — | — | — |
| CT abdomen without contrast | CPT | 74150 | 0 | $3,256.79 | $3,256.79 | — | — | — |
| CT abdomen with contrast | CPT | 74160 | 0 | $5,224.53 | $5,224.53 | — | — | — |
| CT abdomen with and without contrast | CPT | 74170 | 0 | $6,698.46 | $6,698.46 | — | — | — |
| CT abdomen and pelvis without contrast | CPT | 74176 | 0 | $8,242.07 | $8,242.07 | — | — | — |
| CT abdomen and pelvis with contrast | CPT | 74177 | 0 | $11,269 | $11,269 | — | — | — |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 0 | $13,397 | $13,397 | — | — | — |
| MRI abdomen without contrast | CPT | 74181 | 0 | $6,419.81 | $6,419.81 | — | — | — |
| MRI abdomen with and without contrast | CPT | 74183 | 0 | $14,178 | $14,178 | — | — | — |
| Abdominal ultrasound complete | CPT | 76700 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Abdominal ultrasound limited | CPT | 76705 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Retroperitoneal ultrasound complete | CPT | 76770 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Obstetric ultrasound first trimester | CPT | 76801 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Obstetric ultrasound after first trimester | CPT | 76805 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Transvaginal ultrasound | CPT | 76830 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Pelvic ultrasound complete | CPT | 76856 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Scrotal ultrasound | CPT | 76870 | 0 | $2,083.4 | $2,083.4 | — | — | — |
| Diagnostic mammography unilateral | CPT | 77065 | 0 | $540.14 | $540.14 | — | — | — |
| Diagnostic mammography bilateral | CPT | 77066 | 0 | $1,539.09 | $1,539.09 | — | — | — |
| Screening mammography bilateral | CPT | 77067 | 0 | $1,326.1 | $1,326.1 | — | — | — |
| EKG tracing only | CPT | 93005 | 0 | $1,052.23 | $1,052.23 | — | — | — |
| 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, moderate complexity | CPT | 99222 | 0 | $2,823.84 | $2,823.84 | — | — | — |
| lab |
| Basic metabolic panel (BMP) | CPT | 80048 | 0 | $934.26 | $934.26 | — | — | — |
| General health panel | CPT | 80050 | 0 | $2,247.46 | $2,247.46 | — | — | — |
| Electrolyte panel | CPT | 80051 | 0 | $843.53 | $843.53 | — | — | — |
| Comprehensive metabolic panel | CPT | 80053 | 0 | $1,148.7 | $1,148.7 | — | — | — |
| Lipid panel | CPT | 80061 | 0 | $924.56 | $924.56 | — | — | — |
| Renal function panel | CPT | 80069 | 0 | $565.7 | $565.7 | — | — | — |
| Hepatic function panel | CPT | 80076 | 0 | $728.53 | $728.53 | — | — | — |
| Urinalysis automated | CPT | 81003 | 0 | $349.71 | $349.71 | — | — | — |
| Glucose quantitative | CPT | 82947 | 0 | $363.06 | $363.06 | — | — | — |
| Hemoglobin A1c | CPT | 83036 | 0 | $272.21 | $272.21 | — | — | — |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 0 | $607.59 | $607.59 | — | — | — |
| Complete blood count with automated differential | CPT | 85025 | 0 | $491.17 | $491.17 | — | — | — |
| Complete blood count without differential | CPT | 85027 | 0 | $271.33 | $271.33 | — | — | — |
| Urine culture bacterial | CPT | 87086 | 0 | $293.16 | $293.16 | — | — | — |
| Urine culture identification | CPT | 87088 | 0 | $398 | $398 | — | — | — |
| Tissue exam by pathologist level IV | CPT | 88305 | 0 | $1,040.32 | $1,040.32 | — | — | — |
| maternity |
| Fetal non-stress test | CPT | 59025 | 0 | $919.16 | $919.16 | — | — | — |
| Vaginal delivery only | CPT | 59409 | 0 | $3,719.01 | $3,719.01 | — | — | — |
| office |
| Office visit, established patient, 10-19 min | CPT | 99212 | 0 | $444.09 | $444.09 | — | — | — |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 0 | $549.6 | $549.6 | — | — | — |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 0 | $753.78 | $753.78 | — | — | — |
| Office visit, established patient, 40-54 min | CPT | 99215 | 0 | $894.9 | $894.9 | — | — | — |
| preventive |
| Colonoscopy diagnostic | CPT | 45378 | 0 | $4,833.92 | $4,833.92 | — | — | — |
| Colonoscopy with biopsy | CPT | 45380 | 0 | $5,211.41 | $5,211.41 | — | — | — |
| 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 | — | — | — | — | — |
| 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 | $19,821 | $19,821 | — | — | — |
| PCI with drug-eluting stent | CPT | 92928 | 0 | $45,496 | $45,496 | — | — | — |
| Coronary angiography with bypass cath | CPT | 93458 | 0 | $26,160 | $26,160 | — | — | — |
