"Service Bundle Charges for Spencer Municipal Hospital, 1200 First Avenue East, Spencer, Iowa, 51301, Iowa Hospital License 210037H, Data Effective November 1, 2023"																												
DRG/CPT Code Description	DRG	Patient Type	Gross Charge	Average Charge Amount	 Amerigroup Medicaid 	 Amerigroup Medicare Advantage  	Avera Health 	Coventry - Commercial HMO	Coventry - Commercial PPOs 	Coventry Medicare Advantage (HMO and PPO)	First Choice of Midwest	Health Partners	Humana Commercial	"Humana Medicare Advantage  (PPO, HMO, PFFS)"	 Iowa Total Care 	Midlands Choice (All Others)	Midlands Choice  (Morton Bldg)	Midlands Choice (ILCC)	 Molina Healthcare Medicaid 	Sanford	UHC Commercial	UHC Medicare Advantage 	 Wellmark HMO 	 Wellmark Medicare Advantage 	 Wellmark PPO 	 De-identified Minimum Negotiated Charge across all payors 	 De-identified Maximum Negotiated Charge across all payors 	 Discounted Cash Price 
Pulmonary embolism with MCC or acute cor pulmonale	175	I	N/A	" 18,167 "	" 9,083 "	" 10,882 "	" 17,259 "	" 16,350 "	" 16,350 "	" 10,882 "	" 17,259 "	" 14,534 "	" 17,259 "	" 10,991 "	" 9,083 "	" 17,259 "	" 15,442 "	" 15,442 "	" 9,083 "	" 17,259 "	" 16,350 "	" 18,167 "	" 15,641 "	" 10,991 "	" 17,207 "	" 9,083 "	" 18,167 "	" 13,625 "
Respiratory infections and inflammations with MCC	177	I	N/A	" 26,250 "	" 11,396 "	" 13,867 "	" 24,937 "	" 23,625 "	" 23,625 "	" 13,867 "	" 24,937 "	" 21,000 "	" 24,937 "	" 14,006 "	" 11,396 "	" 24,937 "	" 22,312 "	" 22,312 "	" 11,396 "	" 24,937 "	" 23,625 "	" 26,250 "	" 23,643 "	" 14,006 "	" 26,009 "	" 11,396 "	" 26,250 "	" 19,687 "
Pulmonary edema and respiratory failure	189	I	N/A	" 19,752 "	" 8,369 "	" 9,404 "	" 18,764 "	" 17,777 "	" 17,777 "	" 9,404 "	" 18,764 "	" 15,802 "	" 18,764 "	" 9,498 "	" 8,369 "	" 18,764 "	" 16,789 "	" 16,789 "	" 8,369 "	" 18,764 "	" 17,777 "	" 19,752 "	" 6,736 "	" 9,498 "	" 7,411 "	" 6,736 "	" 19,752 "	" 14,814 "
Chronic obstructive pulmonary disease with MCC	190	I	N/A	" 17,286 "	" 7,408 "	" 8,457 "	" 16,421 "	" 15,557 "	" 15,557 "	" 8,457 "	" 16,421 "	" 13,828 "	" 16,421 "	" 8,542 "	" 7,408 "	" 16,421 "	" 14,693 "	" 14,693 "	" 7,408 "	" 16,421 "	" 15,557 "	" 17,286 "	" 18,587 "	" 8,542 "	" 20,447 "	" 7,408 "	" 20,447 "	" 12,964 "
Simple pneumonia and pleurisy with MCC	193	I	N/A	" 21,701 "	" 8,206 "	" 10,118 "	" 20,616 "	" 19,531 "	" 19,531 "	" 10,118 "	" 20,616 "	" 17,361 "	" 20,616 "	" 10,219 "	" 8,206 "	" 20,616 "	" 18,446 "	" 18,446 "	" 8,206 "	" 20,616 "	" 19,531 "	" 21,701 "	" 20,008 "	" 10,219 "	" 22,011 "	" 8,206 "	" 22,011 "	" 16,276 "
Simple pneumonia and pleurisy with CC	194	I	N/A	" 17,297 "	" 5,357 "	" 6,546 "	" 16,432 "	" 15,567 "	" 15,567 "	" 6,546 "	" 16,432 "	" 13,837 "	" 16,432 "	" 6,611 "	" 5,357 "	" 16,432 "	" 14,702 "	" 14,702 "	" 5,357 "	" 16,432 "	" 15,567 "	" 17,297 "	" 6,628 "	" 6,611 "	" 7,291 "	" 5,357 "	" 17,297 "	" 12,972 "
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC	216	I	N/A	 * 	" 84,671 "	" 75,899 "	 * 	 * 	 * 	" 75,899 "	 * 	 * 	 * 	" 76,658 "	" 84,671 "	 * 	 * 	 * 	" 84,671 "	 * 	 * 	 * 	 * 	" 76,658 "	 * 	" 75,899 "	" 84,671 "	 * 
Heart failure and shock with MCC	291	I	N/A	" 19,394 "	" 8,939 "	" 9,971 "	" 18,425 "	" 17,455 "	" 17,455 "	" 9,971 "	" 18,425 "	" 15,516 "	" 18,425 "	" 10,071 "	" 8,939 "	" 18,425 "	" 16,485 "	" 16,485 "	" 8,939 "	" 18,425 "	" 17,455 "	" 19,394 "	" 27,703 "	" 10,071 "	" 30,476 "	" 8,939 "	" 30,476 "	" 14,546 "
Cardiac arrhythmia and conduction disorders with MCC	308	I	N/A	" 22,972 "	" 6,876 "	" 9,136 "	" 21,823 "	" 20,675 "	" 20,675 "	" 9,136 "	" 21,823 "	" 18,378 "	" 21,823 "	" 9,227 "	" 6,876 "	" 21,823 "	" 19,526 "	" 19,526 "	" 6,876 "	" 21,823 "	" 20,675 "	" 22,972 "	" 24,804 "	" 9,227 "	" 27,287 "	" 6,876 "	" 27,287 "	" 17,229 "
Cardiac arrhythmia and conduction disorders with CC	309	I	N/A	" 16,657 "	" 4,681 "	" 5,747 "	" 15,824 "	" 14,991 "	" 14,991 "	" 5,747 "	" 15,824 "	" 13,326 "	" 15,824 "	" 5,804 "	" 4,681 "	" 15,824 "	" 14,159 "	" 14,159 "	" 4,681 "	" 15,824 "	" 14,991 "	" 16,657 "	" 7,250 "	" 5,804 "	" 7,976 "	" 4,681 "	" 16,657 "	" 12,493 "
Major small and large bowel procedures with MCC	329	I	N/A	" 69,390 "	" 25,582 "	" 36,020 "	" 65,920 "	" 62,451 "	" 62,451 "	" 36,020 "	" 65,920 "	" 55,512 "	" 65,920 "	" 36,380 "	" 25,582 "	" 65,920 "	" 58,981 "	" 58,981 "	" 25,582 "	" 65,920 "	" 62,451 "	" 69,390 "	" 53,693 "	" 36,380 "	" 59,067 "	" 25,582 "	" 69,390 "	" 52,042 "
Major small and large bowel procedures with CC	330	I	N/A	" 36,350 "	" 15,600 "	" 19,130 "	" 34,532 "	" 32,715 "	" 32,715 "	" 19,130 "	" 34,532 "	" 29,080 "	" 34,532 "	" 19,321 "	" 15,600 "	" 34,532 "	" 30,897 "	" 30,897 "	" 15,600 "	" 34,532 "	" 32,715 "	" 36,350 "	" 18,487 "	" 19,321 "	" 20,338 "	" 15,600 "	" 36,350 "	" 27,262 "
Major small and large bowel procedures without CC/MCC	331	I	N/A	" 31,071 "	" 11,496 "	" 13,313 "	" 29,518 "	" 27,964 "	" 27,964 "	" 13,313 "	" 29,518 "	" 24,857 "	" 29,518 "	" 13,446 "	" 11,496 "	" 29,518 "	" 26,411 "	" 26,411 "	" 11,496 "	" 29,518 "	" 27,964 "	" 31,071 "	" 13,294 "	" 13,446 "	" 14,625 "	" 11,496 "	" 31,071 "	" 23,304 "
G.I. obstruction with CC	389	I	N/A	" 12,707 "	" 5,811 "	" 6,288 "	" 12,071 "	" 11,436 "	" 11,436 "	" 6,288 "	" 12,071 "	" 10,165 "	" 12,071 "	" 6,351 "	" 5,811 "	" 12,071 "	" 10,801 "	" 10,801 "	" 5,811 "	" 12,071 "	" 11,436 "	" 12,707 "	" 8,227 "	" 6,351 "	" 9,050 "	" 5,811 "	" 12,707 "	" 9,530 "
"Esophagitis, gastroenteritis and miscellaneous digestive disorders without MCC"	392	I	N/A	" 14,655 "	" 4,840 "	" 6,136 "	" 13,923 "	" 13,190 "	" 13,190 "	" 6,136 "	" 13,923 "	" 11,724 "	" 13,923 "	" 6,198 "	" 4,840 "	" 13,923 "	" 12,457 "	" 12,457 "	" 4,840 "	" 13,923 "	" 13,190 "	" 14,655 "	" 6,437 "	" 6,198 "	" 7,082 "	" 4,840 "	" 14,655 "	" 10,992 "
Spinal fusion except cervical without MCC	460	I	N/A	 * 	" 23,799 "	" 29,341 "	 * 	 * 	 * 	" 29,341 "	 * 	 * 	 * 	" 29,634 "	" 23,799 "	 * 	 * 	 * 	" 23,799 "	 * 	 * 	 * 	" 42,883 "	" 29,634 "	" 47,176 "	" 23,799 "	" 47,176 "	 * 
Major hip and knee joint replacement or reattachment of lower extremity without MCC	470	I	N/A	" 43,300 "	" 14,843 "	" 14,896 "	" 41,135 "	" 38,970 "	" 38,970 "	" 14,896 "	" 41,135 "	" 34,640 "	" 41,135 "	" 15,045 "	" 14,843 "	" 41,135 "	" 36,805 "	" 36,805 "	" 14,843 "	" 41,135 "	" 38,970 "	" 43,300 "	" 24,805 "	" 15,045 "	" 27,288 "	" 14,843 "	" 43,300 "	" 32,475 "
Cervical spinal fusion without CC/MCC	473	I	N/A	 * 	" 14,150 "	" 19,751 "	 * 	 * 	 * 	" 19,751 "	 * 	 * 	 * 	" 19,948 "	" 14,150 "	 * 	 * 	 * 	" 14,150 "	 * 	 * 	 * 	 * 	" 19,948 "	 * 	" 14,150 "	" 19,948 "	 * 
Hip and femur procedures except major joint with MCC	480	I	N/A	" 54,371 "	" 21,154 "	" 23,108 "	" 51,653 "	" 48,934 "	" 48,934 "	" 23,108 "	" 51,653 "	" 43,497 "	" 51,653 "	" 23,339 "	" 21,154 "	" 51,653 "	" 46,215 "	" 46,215 "	" 21,154 "	" 51,653 "	" 48,934 "	" 54,371 "	" 53,836 "	" 23,339 "	" 59,225 "	" 21,154 "	" 59,225 "	" 40,778 "
Hip and femur procedures except major joint with CC	481	I	N/A	" 44,303 "	" 15,485 "	" 16,458 "	" 42,087 "	" 39,872 "	" 39,872 "	" 16,458 "	" 42,087 "	" 35,442 "	" 42,087 "	" 16,622 "	" 15,485 "	" 42,087 "	" 37,657 "	" 37,657 "	" 15,485 "	" 42,087 "	" 39,872 "	" 44,303 "	" 23,793 "	" 16,622 "	" 26,174 "	" 15,485 "	" 44,303 "	" 33,227 "
Major joint/limb reattachment procedure of upper extremities	483	I	N/A	" 69,181 "	" 17,620 "	" 18,368 "	" 65,722 "	" 62,263 "	" 62,263 "	" 18,368 "	" 65,722 "	" 55,345 "	" 65,722 "	" 18,552 "	" 17,620 "	" 65,722 "	" 58,804 "	" 58,804 "	" 17,620 "	" 65,722 "	" 62,263 "	" 69,181 "	" 13,344 "	" 18,552 "	" 14,680 "	" 13,344 "	" 69,181 "	" 51,886 "
Hip replacement with principal diagnosis of hip fracture with MCC	521	I	N/A	" 52,545 "	" 22,357 "	" 23,523 "	" 49,918 "	" 47,290 "	" 47,290 "	" 23,523 "	" 49,918 "	" 42,036 "	" 49,918 "	" 23,758 "	" 22,357 "	" 49,918 "	" 44,663 "	" 44,663 "	" 22,357 "	" 49,918 "	" 47,290 "	" 52,545 "	" 40,400 "	" 23,758 "	" 44,444 "	" 22,357 "	" 52,545 "	" 39,409 "
Hip replacement with principal diagnosis of hip fracture without MCC	522	I	N/A	" 50,789 "	" 17,485 "	" 16,929 "	" 48,250 "	" 45,710 "	" 45,710 "	" 16,929 "	" 48,250 "	" 40,631 "	" 48,250 "	" 17,098 "	" 17,485 "	" 48,250 "	" 43,171 "	" 43,171 "	" 17,485 "	" 48,250 "	" 45,710 "	" 50,789 "	" 18,087 "	" 17,098 "	" 19,897 "	" 16,929 "	" 50,789 "	" 38,092 "
Cellulitis without MCC	603	I	N/A	" 15,567 "	" 5,209 "	" 6,870 "	" 14,788 "	" 14,010 "	" 14,010 "	" 6,870 "	" 14,788 "	" 12,453 "	" 14,788 "	" 6,939 "	" 5,209 "	" 14,788 "	" 13,232 "	" 13,232 "	" 5,209 "	" 14,788 "	" 14,010 "	" 15,567 "	" 7,322 "	" 6,939 "	" 8,054 "	" 5,209 "	" 15,567 "	" 11,675 "
Diabetes with CC	638	I	N/A	" 16,143 "	" 5,169 "	" 6,825 "	" 15,336 "	" 14,529 "	" 14,529 "	" 6,825 "	" 15,336 "	" 12,914 "	" 15,336 "	" 6,893 "	" 5,169 "	" 15,336 "	" 13,721 "	" 13,721 "	" 5,169 "	" 15,336 "	" 14,529 "	" 16,143 "	" 7,674 "	" 6,893 "	" 8,442 "	" 5,169 "	" 16,143 "	" 12,107 "
"iscellaneous disorders of nutrition, metabolism, fluids and electrolytes without MCC"	641	I	N/A	" 14,912 "	" 4,492 "	" 6,001 "	" 14,167 "	" 13,421 "	" 13,421 "	" 6,001 "	" 14,167 "	" 11,930 "	" 14,167 "	" 6,061 "	" 4,492 "	" 14,167 "	" 12,675 "	" 12,675 "	" 4,492 "	" 14,167 "	" 13,421 "	" 14,912 "	" 6,464 "	" 6,061 "	" 7,112 "	" 4,492 "	" 14,912 "	" 11,184 "
Renal failure with MCC	682	I	N/A	" 20,735 "	" 8,845 "	" 11,582 "	" 19,698 "	" 18,661 "	" 18,661 "	" 11,582 "	" 19,698 "	" 16,588 "	" 19,698 "	" 11,698 "	" 8,845 "	" 19,698 "	" 17,624 "	" 17,624 "	" 8,845 "	" 19,698 "	" 18,661 "	" 20,735 "	" 34,713 "	" 11,698 "	" 38,188 "	" 8,845 "	" 38,188 "	" 15,551 "
Renal failure with CC	683	I	N/A	" 14,286 "	" 5,376 "	" 6,972 "	" 13,572 "	" 12,857 "	" 12,857 "	" 6,972 "	" 13,572 "	" 11,429 "	" 13,572 "	" 7,042 "	" 5,376 "	" 13,572 "	" 12,143 "	" 12,143 "	" 5,376 "	" 13,572 "	" 12,857 "	" 14,286 "	" 9,036 "	" 7,042 "	" 9,940 "	" 5,376 "	" 14,286 "	" 10,714 "
Kidney and urinary tract infections with MCC	689	I	N/A	" 23,800 "	" 6,864 "	" 8,937 "	" 22,610 "	" 21,420 "	" 21,420 "	" 8,937 "	" 22,610 "	" 19,040 "	" 22,610 "	" 9,026 "	" 6,864 "	" 22,610 "	" 20,230 "	" 20,230 "	" 6,864 "	" 22,610 "	" 21,420 "	" 23,800 "	" 19,147 "	" 9,026 "	" 21,064 "	" 6,864 "	" 23,800 "	" 17,850 "
Kidney and urinary tract infections without MCC	690	I	N/A	" 18,494 "	" 4,781 "	" 6,199 "	" 17,569 "	" 16,644 "	" 16,644 "	" 6,199 "	" 17,569 "	" 14,795 "	" 17,569 "	" 6,261 "	" 4,781 "	" 17,569 "	" 15,720 "	" 15,720 "	" 4,781 "	" 17,569 "	" 16,644 "	" 18,494 "	" 6,936 "	" 6,261 "	" 7,630 "	" 4,781 "	" 18,494 "	" 13,870 "
Uterine and adnexa procedures for non-malignancy without CC/MCC	743	I	N/A	" 22,740 "	" 6,708 "	" 9,120 "	" 21,603 "	" 20,466 "	" 20,466 "	" 9,120 "	" 21,603 "	" 18,192 "	" 21,603 "	" 9,211 "	" 6,708 "	" 21,603 "	" 19,329 "	" 19,329 "	" 6,708 "	" 21,603 "	" 20,466 "	" 22,740 "	" 15,280 "	" 9,211 "	" 16,810 "	" 6,708 "	" 22,740 "	" 17,055 "
Vaginal delivery with O.R. proc except steril &/or D&C	768	I	N/A	" 13,179 "	" 5,062 "	" 8,935 "	" 12,520 "	" 11,861 "	" 11,861 "	" 8,935 "	" 12,520 "	" 10,543 "	" 12,520 "	" 9,024 "	" 5,062 "	" 12,520 "	" 11,202 "	" 11,202 "	" 5,062 "	" 12,520 "	" 11,861 "	" 13,179 "	" 7,140 "	" 9,024 "	" 7,855 "	" 5,062 "	" 13,179 "	" 9,885 "
Cesarean section with sterilization without CC/MCC	785	I	N/A	" 17,158 "	" 6,206 "	" 7,106 "	" 16,300 "	" 15,442 "	" 15,442 "	" 7,106 "	" 16,300 "	" 13,726 "	" 16,300 "	" 7,177 "	" 6,206 "	" 16,300 "	" 14,584 "	" 14,584 "	" 6,206 "	" 16,300 "	" 15,442 "	" 17,158 "	" 9,071 "	" 7,177 "	" 9,979 "	" 6,206 "	" 17,158 "	" 12,868 "
Cesarean section without sterilization with CC	787	I	N/A	" 24,827 "	" 7,396 "	" 8,300 "	" 23,586 "	" 22,344 "	" 22,344 "	" 8,300 "	" 23,586 "	" 19,862 "	" 23,586 "	" 8,383 "	" 7,396 "	" 23,586 "	" 21,103 "	" 21,103 "	" 7,396 "	" 23,586 "	" 22,344 "	" 24,827 "	" 11,571 "	" 8,383 "	" 12,729 "	" 7,396 "	" 24,827 "	" 18,620 "
Cesarean section without sterilization without CC/MCC	788	I	N/A	" 17,735 "	" 6,589 "	" 6,797 "	" 16,849 "	" 15,962 "	" 15,962 "	" 6,797 "	" 16,849 "	" 14,188 "	" 16,849 "	" 6,865 "	" 6,589 "	" 16,849 "	" 15,075 "	" 15,075 "	" 6,589 "	" 16,849 "	" 15,962 "	" 17,735 "	" 9,301 "	" 6,865 "	" 10,232 "	" 6,589 "	" 17,735 "	" 13,302 "
"Neonates, died or transferred to another acute care facility"	789	I	N/A	" 3,754 "	" 1,848 "	" 14,225 "	" 3,567 "	" 3,379 "	" 3,379 "	" 14,225 "	" 3,567 "	" 3,004 "	" 3,567 "	" 14,367 "	" 1,848 "	" 3,567 "	" 3,191 "	" 3,191 "	" 1,848 "	" 3,567 "	" 3,379 "	" 3,754 "	" 88,381 "	" 14,367 "	" 97,228 "	" 1,848 "	" 97,228 "	" 2,816 "
Neonate with other significant problems	794	I	N/A	" 6,775 "	" 2,517 "	" 11,648 "	" 6,436 "	" 6,097 "	" 6,097 "	" 11,648 "	" 6,436 "	" 5,420 "	" 6,436 "	" 11,765 "	" 2,517 "	" 6,436 "	" 5,759 "	" 5,759 "	" 2,517 "	" 6,436 "	" 6,097 "	" 6,775 "	" 14,930 "	" 11,765 "	" 16,425 "	" 2,517 "	" 16,425 "	" 5,081 "
Normal newborn	795	I	N/A	" 5,662 "	" 2,191 "	" 1,577 "	" 5,379 "	" 5,095 "	" 5,095 "	" 1,577 "	" 5,379 "	" 4,529 "	" 5,379 "	" 1,593 "	" 2,191 "	" 5,379 "	" 4,812 "	" 4,812 "	" 2,191 "	" 5,379 "	" 5,095 "	" 5,662 "	" 7,525 "	" 1,593 "	" 8,278 "	" 1,577 "	" 8,278 "	" 4,246 "
Vaginal delivery without sterilization/D&C with CC	806	I	N/A	" 11,191 "	" 4,815 "	" 5,437 "	" 10,632 "	" 10,072 "	" 10,072 "	" 5,437 "	" 10,632 "	" 8,953 "	" 10,632 "	" 5,491 "	" 4,815 "	" 10,632 "	" 9,512 "	" 9,512 "	" 4,815 "	" 10,632 "	" 10,072 "	" 11,191 "	" 6,787 "	" 5,491 "	" 7,466 "	" 4,815 "	" 11,191 "	" 8,393 "
Vaginal delivery without sterilization/D&C without CC/MCC	807	I	N/A	" 11,459 "	" 4,519 "	" 4,919 "	" 10,886 "	" 10,313 "	" 10,313 "	" 4,919 "	" 10,886 "	" 9,167 "	" 10,886 "	" 4,968 "	" 4,519 "	" 10,886 "	" 9,740 "	" 9,740 "	" 4,519 "	" 10,886 "	" 10,313 "	" 11,459 "	" 6,154 "	" 4,968 "	" 6,770 "	" 4,519 "	" 11,459 "	" 8,594 "
Infectious and parasitic diseases with O.R. procedure with MCC	853	I	N/A	" 44,172 "	" 27,864 "	" 38,184 "	" 41,963 "	" 39,754 "	" 39,754 "	" 38,184 "	" 41,963 "	" 35,337 "	" 41,963 "	" 38,566 "	" 27,864 "	" 41,963 "	" 37,546 "	" 37,546 "	" 27,864 "	" 41,963 "	" 39,754 "	" 44,172 "	" 69,769 "	" 38,566 "	" 76,753 "	" 27,864 "	" 76,753 "	" 33,129 "
Infectious and parasitic diseases with O.R. procedure with CC	854	I	N/A	" 28,818 "	" 12,108 "	" 16,015 "	" 27,377 "	" 25,936 "	" 25,936 "	" 16,015 "	" 27,377 "	" 23,054 "	" 27,377 "	" 16,175 "	" 12,108 "	" 27,377 "	" 24,495 "	" 24,495 "	" 12,108 "	" 27,377 "	" 25,936 "	" 28,818 "	" 21,821 "	" 16,175 "	" 24,005 "	" 12,108 "	" 28,818 "	" 21,613 "
Septicemia or severe sepsis without MV >96 hours with MCC	871	I	N/A	" 26,699 "	" 10,944 "	" 15,249 "	" 25,364 "	" 24,029 "	" 24,029 "	" 15,249 "	" 25,364 "	" 21,359 "	" 25,364 "	" 15,401 "	" 10,944 "	" 25,364 "	" 22,694 "	" 22,694 "	" 10,944 "	" 25,364 "	" 24,029 "	" 26,699 "	" 36,474 "	" 15,401 "	" 40,125 "	" 10,944 "	" 40,125 "	" 20,024 "
Septicemia or severe sepsis without MV >96 hours without MCC	872	I	N/A	" 22,615 "	" 6,037 "	" 8,009 "	" 21,484 "	" 20,354 "	" 20,354 "	" 8,009 "	" 21,484 "	" 18,092 "	" 21,484 "	" 8,089 "	" 6,037 "	" 21,484 "	" 19,223 "	" 19,223 "	" 6,037 "	" 21,484 "	" 20,354 "	" 22,615 "	" 12,226 "	" 8,089 "	" 13,450 "	" 6,037 "	" 22,615 "	" 16,961 "
Acute adjustment reaction and psychosocial dysfunction	880	I	N/A	" 7,127 "	" 4,117 "	" 7,060 "	" 6,771 "	" 6,415 "	" 6,415 "	" 7,060 "	" 6,771 "	" 5,702 "	" 6,771 "	" 7,131 "	" 4,117 "	" 6,771 "	" 6,058 "	" 6,058 "	" 4,117 "	" 6,771 "	" 6,415 "	" 7,127 "	" 5,594 "	" 7,131 "	" 6,154 "	" 4,117 "	" 7,131 "	" 5,346 "
Depressive neuroses	881	I	N/A	" 6,274 "	" 4,383 "	" 6,665 "	" 5,960 "	" 5,647 "	" 5,647 "	" 6,665 "	" 5,960 "	" 5,019 "	" 5,960 "	" 6,732 "	" 4,383 "	" 5,960 "	" 5,333 "	" 5,333 "	" 4,383 "	" 5,960 "	" 5,647 "	" 6,274 "	" 5,304 "	" 6,732 "	" 5,835 "	" 4,383 "	" 6,732 "	" 4,706 "
Neuroses except depressive	882	I	N/A	" 5,715 "	" 3,818 "	" 6,805 "	" 5,429 "	" 5,144 "	" 5,144 "	" 6,805 "	" 5,429 "	" 4,572 "	" 5,429 "	" 6,873 "	" 3,818 "	" 5,429 "	" 4,858 "	" 4,858 "	" 3,818 "	" 5,429 "	" 5,144 "	" 5,715 "	" 4,214 "	" 6,873 "	" 4,636 "	" 3,818 "	" 6,873 "	" 4,286 "
Disorders of personality and impulse control	883	I	N/A	" 7,160 "	" 4,537 "	" 12,579 "	" 6,802 "	" 6,444 "	" 6,444 "	" 12,579 "	" 6,802 "	" 5,728 "	" 6,802 "	" 12,704 "	" 4,537 "	" 6,802 "	" 6,086 "	" 6,086 "	" 4,537 "	" 6,802 "	" 6,444 "	" 7,160 "	" 4,827 "	" 12,704 "	" 5,310 "	" 4,537 "	" 12,704 "	" 5,370 "
Psychoses	885	I	N/A	" 10,886 "	" 5,398 "	" 10,093 "	" 10,342 "	" 9,798 "	" 9,798 "	" 10,093 "	" 10,342 "	" 8,709 "	" 10,342 "	" 10,194 "	" 5,398 "	" 10,342 "	" 9,253 "	" 9,253 "	" 5,398 "	" 10,342 "	" 9,798 "	" 10,886 "	" 6,674 "	" 10,194 "	" 7,342 "	" 5,398 "	" 10,886 "	" 8,165 "
"Alcohol, drug abuse or dependence without rehabilitation therapy without MCC"	897	I	N/A	" 8,242 "	" 5,298 "	" 6,632 "	" 7,830 "	" 7,418 "	" 7,418 "	" 6,632 "	" 7,830 "	" 6,594 "	" 7,830 "	" 6,699 "	" 5,298 "	" 7,830 "	" 7,006 "	" 7,006 "	" 5,298 "	" 7,830 "	" 7,418 "	" 8,242 "	" 7,144 "	" 6,699 "	" 7,859 "	" 5,298 "	" 8,242 "	" 6,182 "
Poisoning and toxic effects of drugs without MCC	918	I	N/A	" 15,254 "	" 3,919 "	" 6,371 "	" 14,491 "	" 13,729 "	" 13,729 "	" 6,371 "	" 14,491 "	" 12,203 "	" 14,491 "	" 6,434 "	" 3,919 "	" 14,491 "	" 12,966 "	" 12,966 "	" 3,919 "	" 14,491 "	" 13,729 "	" 15,254 "	" 4,508 "	" 6,434 "	" 4,959 "	" 3,919 "	" 15,254 "	" 11,441 "
																												
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* - No standard gross charge exists. Average charge amount calculated based on previous claims submitted; no claim data available to calculate