| Psychoses | MS-DRG 885 | $10,813 |
| ED visit level 1 | CPT 99281 | $80.5 |
| ED visit level 2 | CPT 99282 | $144.78 |
| ED visit level 3 | CPT 99283 | $253.15 |
| ED visit level 4 | CPT 99284 | $389.31 |
| ED visit level 5 | CPT 99285 | $560.53 |
| Critical care, first hour | CPT 99291 | $770.36 |
| CT head without contrast | CPT 70450 | $97.22 |
| CT head with contrast | CPT 70460 | $162.76 |
| CT head with and without contrast | CPT 70470 | $162.76 |
| CT neck with contrast | CPT 70491 | $162.76 |
| MRI brain without contrast | CPT 70551 | $220.99 |
| MRI brain with contrast | CPT 70552 | $326.51 |
| MRI brain with and without contrast | CPT 70553 | $326.51 |
| Chest X-ray single view | CPT 71045 | $80.5 |
| Chest X-ray 2 views | CPT 71046 | — |
| CT chest without contrast | CPT 71250 | — |
| CT chest with contrast | CPT 71260 | $162.76 |
| CT chest with and without contrast | CPT 71270 | — |
| MRI chest without contrast | CPT 71550 | $220.99 |
| MRI chest with contrast | CPT 71551 | $722.32 |
| MRI chest with and without contrast | CPT 71552 | $326.51 |
| Lumbosacral spine X-ray | CPT 72100 | $97.22 |
| CT cervical spine without contrast | CPT 72125 | $97.22 |
| CT thoracic spine without contrast | CPT 72128 | $97.22 |
| CT lumbar spine without contrast | CPT 72131 | $97.22 |
| MRI cervical spine without contrast | CPT 72141 | $220.99 |
| MRI thoracic spine without contrast | CPT 72146 | $220.99 |
| MRI lumbar spine without contrast | CPT 72148 | $220.99 |
| MRI lumbar spine with and without contrast | CPT 72149 | $326.51 |
| MRI cervical spine with and without contrast | CPT 72156 | $326.51 |
| MRI lumbar spine with contrast | CPT 72158 | $326.51 |
| CT pelvis without contrast | CPT 72192 | $97.22 |
| CT pelvis with contrast | CPT 72193 | $162.76 |
| Shoulder X-ray | CPT 73030 | $80.5 |
| Humerus X-ray | CPT 73060 | $80.5 |
| Hand X-ray 3 views | CPT 73130 | $80.5 |
| MRI upper extremity joint without contrast | CPT 73221 | — |
| MRI upper extremity joint with and without contrast | CPT 73223 | — |
| Knee X-ray 1-2 views | CPT 73560 | $80.5 |
| Ankle X-ray 3 views | CPT 73610 | $80.5 |
| MRI lower extremity joint without contrast | CPT 73721 | $220.99 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $326.51 |
| CT abdomen without contrast | CPT 74150 | $97.22 |
| CT abdomen with contrast | CPT 74160 | $162.76 |
| CT abdomen with and without contrast | CPT 74170 | $162.76 |
| CT abdomen and pelvis without contrast | CPT 74176 | $220.99 |
| CT abdomen and pelvis with contrast | CPT 74177 | $326.51 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $326.51 |
| MRI abdomen without contrast | CPT 74181 | $220.99 |
| MRI abdomen with and without contrast | CPT 74183 | $326.51 |
| Abdominal ultrasound complete | CPT 76700 | $97.22 |
| Abdominal ultrasound limited | CPT 76705 | $97.22 |
| Retroperitoneal ultrasound complete | CPT 76770 | $97.22 |
| Obstetric ultrasound first trimester | CPT 76801 | $97.22 |
| Obstetric ultrasound after first trimester | CPT 76805 | — |
| Transvaginal ultrasound | CPT 76830 | $97.22 |
| Pelvic ultrasound complete | CPT 76856 | $97.22 |
| Scrotal ultrasound | CPT 76870 | $97.22 |
| Diagnostic mammography unilateral | CPT 77065 | $75.3 |
| Diagnostic mammography bilateral | CPT 77066 | — |
| Screening mammography bilateral | CPT 77067 | $79.68 |
| EKG tracing only | CPT 93005 | $54.31 |
| EKG interpretation only | CPT 93010 | $10.44 |
| Transthoracic echocardiogram complete | CPT 93306 | $722.32 |
| Transthoracic echocardiogram | CPT 93307 | $220.99 |
| Stress echocardiogram | CPT 93350 | $501.29 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,097 |
| COPD w MCC | MS-DRG 190 | $8,574.71 |
| COPD w CC | MS-DRG 191 | $6,525.67 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,969.72 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,238.47 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,865.22 |
| AMI discharged alive w MCC | MS-DRG 280 | $12,417 |
| AMI discharged alive w CC | MS-DRG 281 | $7,114.76 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $5,597.52 |
| Heart failure & shock w MCC | MS-DRG 291 | $9,937.9 |
| Heart failure & shock w CC | MS-DRG 292 | $6,572.11 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,381.41 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,320.17 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,695.06 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,382.18 |
| GI hemorrhage w CC | MS-DRG 378 | $7,591.6 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,879.93 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,034.89 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,136 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,981.88 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,266.34 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,037 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $7,921.37 |
| Basic metabolic panel (BMP) | CPT 80048 | $37.17 |
| Electrolyte panel | CPT 80051 | $7.01 |
| Comprehensive metabolic panel | CPT 80053 | $82.76 |
| Lipid panel | CPT 80061 | — |
| Renal function panel | CPT 80069 | $37.66 |
| Hepatic function panel | CPT 80076 | $58.59 |
| Urinalysis automated | CPT 81003 | — |
| Glucose quantitative | CPT 82947 | — |
| Hemoglobin A1c | CPT 83036 | — |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $87.64 |
| Complete blood count with automated differential | CPT 85025 | $31.46 |
| Complete blood count without differential | CPT 85027 | $27.03 |
| Urine culture bacterial | CPT 87086 | $31.43 |
| Tissue exam by pathologist level IV | CPT 88305 | $48.85 |
| Fetal non-stress test | CPT 59025 | — |
| Office visit, new patient, 15-29 min | CPT 99202 | $39.11 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | — |
| Office visit, new patient, 45-59 min | CPT 99204 | — |
| Office visit, new patient, 60-74 min | CPT 99205 | — |
| Office visit, established patient, 5 min | CPT 99211 | $7.37 |
| Office visit, established patient, 10-19 min | CPT 99212 | $29.48 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | — |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $80.51 |
| Office visit, established patient, 40-54 min | CPT 99215 | $119.41 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $35,582 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $18,557 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,027 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,095 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $10,573 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,374 |
| Major joint replacement w MCC | MS-DRG 469 | $23,480 |
| Major joint replacement w/o MCC | MS-DRG 470 | $14,932 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,544 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,214 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $12,626 |
| OR procedure for obesity w MCC | MS-DRG 619 | $22,351 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,036 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,287 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,604.26 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $15,862 |
| PCI single major coronary artery | CPT 92920 | $5,212.67 |
| PCI with drug-eluting stent | CPT 92928 | $10,368 |
| Left heart catheterization | CPT 93452 | $2,940.64 |
| Coronary angiography with cath | CPT 93455 | $2,940.64 |
| Coronary angiography with bypass cath | CPT 93458 | $2,940.64 |
