| Psychoses | MS-DRG 885 | $16,091 |
| ED visit level 1 | CPT 99281 | $368.00 |
| ED visit level 2 | CPT 99282 | $467.20 |
| ED visit level 3 | CPT 99283 | $760.96 |
| ED visit level 4 | CPT 99284 | $1,271.04 |
| ED visit level 5 | CPT 99285 | $2,326.50 |
| Critical care, first hour | CPT 99291 | $1,989.55 |
| CT head without contrast | CPT 70450 | $112.78 |
| CT head with contrast | CPT 70460 | $185.05 |
| CT head with and without contrast | CPT 70470 | $185.05 |
| CT neck with contrast | CPT 70491 | $185.05 |
| MRI brain without contrast | CPT 70551 | $238.37 |
| MRI brain with contrast | CPT 70552 | $839.42 |
| MRI brain with and without contrast | CPT 70553 | $839.42 |
| Chest X-ray single view | CPT 71045 | $215.82 |
| Chest X-ray 2 views | CPT 71046 | $215.82 |
| Chest X-ray 3 views | CPT 71047 | $215.82 |
| CT chest without contrast | CPT 71250 | $112.78 |
| CT chest with contrast | CPT 71260 | $185.05 |
| CT chest with and without contrast | CPT 71270 | $185.05 |
| MRI chest without contrast | CPT 71550 | $238.37 |
| MRI chest with contrast | CPT 71551 | $735.01 |
| MRI chest with and without contrast | CPT 71552 | $381.49 |
| Lumbosacral spine X-ray | CPT 72100 | $112.78 |
| CT cervical spine without contrast | CPT 72125 | $112.78 |
| CT thoracic spine without contrast | CPT 72128 | $112.78 |
| CT lumbar spine without contrast | CPT 72131 | $112.78 |
| MRI cervical spine without contrast | CPT 72141 | $238.37 |
| MRI thoracic spine without contrast | CPT 72146 | $238.37 |
| MRI lumbar spine without contrast | CPT 72148 | $238.37 |
| MRI lumbar spine with and without contrast | CPT 72149 | $381.49 |
| MRI cervical spine with and without contrast | CPT 72156 | $381.49 |
| MRI lumbar spine with contrast | CPT 72158 | $381.49 |
| CT pelvis without contrast | CPT 72192 | $112.78 |
| CT pelvis with contrast | CPT 72193 | $185.05 |
| Shoulder X-ray | CPT 73030 | $85.27 |
| Humerus X-ray | CPT 73060 | $431.64 |
| Hand X-ray 3 views | CPT 73130 | $89.17 |
| MRI upper extremity joint without contrast | CPT 73221 | $238.37 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $381.49 |
| Knee X-ray 1-2 views | CPT 73560 | $88.79 |
| Ankle X-ray 3 views | CPT 73610 | $89.17 |
| MRI lower extremity joint without contrast | CPT 73721 | $238.37 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $381.49 |
| CT abdomen without contrast | CPT 74150 | $112.78 |
| CT abdomen with contrast | CPT 74160 | $185.05 |
| CT abdomen with and without contrast | CPT 74170 | $185.05 |
| CT abdomen and pelvis without contrast | CPT 74176 | $238.37 |
| CT abdomen and pelvis with contrast | CPT 74177 | $381.49 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $381.49 |
| MRI abdomen without contrast | CPT 74181 | $238.37 |
| MRI abdomen with and without contrast | CPT 74183 | $381.49 |
| Abdominal ultrasound complete | CPT 76700 | $125.21 |
| Abdominal ultrasound limited | CPT 76705 | $125.21 |
| Retroperitoneal ultrasound complete | CPT 76770 | $125.21 |
| Obstetric ultrasound first trimester | CPT 76801 | $922.02 |
| Obstetric ultrasound after first trimester | CPT 76805 | $608.52 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $238.37 |
| Transvaginal ultrasound | CPT 76830 | $125.21 |
| Pelvic ultrasound complete | CPT 76856 | $125.21 |
| Scrotal ultrasound | CPT 76870 | $704.88 |
| EKG tracing only | CPT 93005 | $350.30 |
| Transthoracic echocardiogram complete | CPT 93306 | $538.00 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $26,289 |
| COPD w MCC | MS-DRG 190 | $14,941 |
| COPD w CC | MS-DRG 191 | $12,572 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,889.35 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $12,043 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $9,465.68 |
| AMI discharged alive w MCC | MS-DRG 280 | $22,845 |
| AMI discharged alive w CC | MS-DRG 281 | $13,230 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,323 |
| Heart failure & shock w MCC | MS-DRG 291 | $16,466 |
| Heart failure & shock w CC | MS-DRG 292 | $12,276 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $8,386.62 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $15,591 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,670 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,950.15 |
| GI hemorrhage w CC | MS-DRG 378 | $13,200 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $9,059.08 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,942.38 |
| Fractures of femur w/o MCC | MS-DRG 533 | $18,387 |
| Kidney/UTI w MCC | MS-DRG 689 | $14,466 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $10,309 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $24,307 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $14,591 |
| Basic metabolic panel (BMP) | CPT 80048 | $150.48 |
| Electrolyte panel | CPT 80051 | $85.80 |
| Comprehensive metabolic panel | CPT 80053 | $165.00 |
| Lipid panel | CPT 80061 | $236.94 |
| Renal function panel | CPT 80069 | $187.44 |
| Hepatic function panel | CPT 80076 | $137.94 |
| Urinalysis automated | CPT 81003 | $61.38 |
| Glucose quantitative | CPT 82947 | $10.59 |
| Hemoglobin A1c | CPT 83036 | $133.98 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $225.72 |
| Complete blood count with automated differential | CPT 85025 | $146.52 |
| Complete blood count without differential | CPT 85027 | $110.88 |
| Fetal non-stress test | CPT 59025 | $185.50 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $4,573.57 |
| Vaginal delivery only | CPT 59409 | $2,583.39 |
| Vaginal delivery with postpartum | CPT 59410 | $3,435.79 |
| Routine obstetric care with C-section | CPT 59510 | $4,573.57 |
| C-section delivery only | CPT 59514 | $3,029.50 |
| C-section with postpartum | CPT 59515 | $2,298.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | $257.92 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $343.04 |
| Office visit, new patient, 45-59 min | CPT 99204 | $434.56 |
| Office visit, new patient, 60-74 min | CPT 99205 | $526.72 |
| Office visit, established patient, 5 min | CPT 99211 | $277.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $224.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $302.72 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $401.28 |
| Office visit, established patient, 40-54 min | CPT 99215 | $481.92 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,496.73 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,852.76 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,496.73 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,496.73 |
| Colonoscopy diagnostic | CPT 45378 | $1,852.76 |
| Colonoscopy with biopsy | CPT 45380 | $1,852.76 |
| Colonoscopy with polyp removal | CPT 45385 | $1,852.76 |
| Total shoulder arthroplasty | CPT 23472 | $6,465.88 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $44,418 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $28,053 |
| Hip hemiarthroplasty | CPT 27125 | $7,116.00 |
| Total hip replacement | CPT 27130 | $10,640 |
| Total knee replacement | CPT 27447 | $10,640 |
| Knee revision arthroplasty single component | CPT 27486 | $6,154.45 |
| Knee revision arthroplasty all components | CPT 27487 | $6,195.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,659.00 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $5,890.93 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,141.09 |
| ACL reconstruction | CPT 29888 | $6,169.85 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $63,438 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $36,243 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $24,044 |
| CABG single arterial graft | CPT 33533 | $4,081.50 |
| CABG 2 arterial grafts | CPT 33534 | $4,081.50 |
| CABG 3 arterial grafts | CPT 33535 | $4,629.50 |
| CABG 4+ arterial grafts | CPT 33536 | $4,629.50 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $21,928 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $17,077 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $47,461 |
| Open appendectomy | CPT 44950 | $3,135.09 |
| Laparoscopic appendectomy | CPT 44970 | $4,983.62 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $87,421 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $51,032 |
| Major joint replacement w MCC | MS-DRG 469 | $40,685 |
| Major joint replacement w/o MCC | MS-DRG 470 | $27,017 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,133.13 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,133.13 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $39,284 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $28,440 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $23,398 |
| Open umbilical hernia repair | CPT 49560 | $3,135.09 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,135.09 |
| Lap inguinal hernia repair | CPT 49650 | $4,983.62 |
| Lap incisional hernia repair | CPT 49652 | $5,046.81 |
| Total abdominal hysterectomy | CPT 58150 | $3,989.00 |
| Vaginal hysterectomy | CPT 58260 | $4,342.60 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,266.58 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $7,232.76 |
| Lap salpingo-oophorectomy | CPT 58661 | $4,983.62 |
| OR procedure for obesity w MCC | MS-DRG 619 | $39,866 |
| OR procedure for obesity w CC | MS-DRG 620 | $25,060 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $22,706 |
| Complex cataract surgery | CPT 66982 | $2,993.00 |
| Cataract surgery with lens implant | CPT 66984 | $2,993.00 |
| Intravitreal injection | CPT 67028 | $1,372.50 |
| Vitrectomy mechanical | CPT 67042 | $4,561.48 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,707 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $21,982 |
