| Psychoses | MS-DRG 885 | $20,872 |
| Psychiatric eval with medical services | CPT 90792 | $70.61 |
| ED visit level 1 | CPT 99281 | $76.01 |
| ED visit level 2 | CPT 99282 | $137.65 |
| ED visit level 3 | CPT 99283 | $242.51 |
| ED visit level 4 | CPT 99284 | $448.6 |
| ED visit level 5 | CPT 99285 | $547.17 |
| Critical care, first hour | CPT 99291 | $1,402.13 |
| CT head without contrast | CPT 70450 | $1,281.29 |
| CT head with contrast | CPT 70460 | $1,143.76 |
| CT head with and without contrast | CPT 70470 | $1,227.32 |
| CT neck with contrast | CPT 70491 | $1,134.56 |
| MRI brain without contrast | CPT 70551 | $938.03 |
| MRI brain with contrast | CPT 70552 | $1,474.29 |
| MRI brain with and without contrast | CPT 70553 | $1,675.18 |
| Chest X-ray single view | CPT 71045 | $108.63 |
| Chest X-ray 2 views | CPT 71046 | $166.48 |
| CT chest without contrast | CPT 71250 | $700.44 |
| CT chest with contrast | CPT 71260 | $1,104.38 |
| CT chest with and without contrast | CPT 71270 | $1,155.54 |
| MRI chest without contrast | CPT 71550 | $952.43 |
| MRI chest with contrast | CPT 71551 | $1,328.62 |
| MRI chest with and without contrast | CPT 71552 | $1,424.1 |
| Lumbosacral spine X-ray | CPT 72100 | $256.61 |
| CT cervical spine without contrast | CPT 72125 | $1,064.51 |
| CT thoracic spine without contrast | CPT 72128 | $1,064.51 |
| CT lumbar spine without contrast | CPT 72131 | $1,109.41 |
| MRI cervical spine without contrast | CPT 72141 | $982.08 |
| MRI thoracic spine without contrast | CPT 72146 | $1,112.56 |
| MRI lumbar spine without contrast | CPT 72148 | $978.75 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,351.49 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,584.07 |
| MRI lumbar spine with contrast | CPT 72158 | $1,553.38 |
| CT pelvis without contrast | CPT 72192 | $1,069.51 |
| CT pelvis with contrast | CPT 72193 | $1,133.68 |
| Shoulder X-ray | CPT 73030 | $168.03 |
| Humerus X-ray | CPT 73060 | $330.58 |
| Hand X-ray 3 views | CPT 73130 | $177.1 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,038.81 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,384.52 |
| Knee X-ray 1-2 views | CPT 73560 | $170.8 |
| Ankle X-ray 3 views | CPT 73610 | $347.27 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,226.68 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,668.17 |
| CT abdomen without contrast | CPT 74150 | $727.47 |
| CT abdomen with contrast | CPT 74160 | $1,091.49 |
| CT abdomen with and without contrast | CPT 74170 | $1,155.17 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,079.71 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,314.32 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,416.16 |
| MRI abdomen without contrast | CPT 74181 | $1,082.19 |
| MRI abdomen with and without contrast | CPT 74183 | $1,745.25 |
| Abdominal ultrasound complete | CPT 76700 | $500.55 |
| Abdominal ultrasound limited | CPT 76705 | $427.77 |
| Retroperitoneal ultrasound complete | CPT 76770 | $413.13 |
| Obstetric ultrasound first trimester | CPT 76801 | $394.1 |
| Obstetric ultrasound after first trimester | CPT 76805 | $358.73 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $367.41 |
| Transvaginal ultrasound | CPT 76830 | $347.38 |
| Pelvic ultrasound complete | CPT 76856 | $449.83 |
| Scrotal ultrasound | CPT 76870 | $385.09 |
| EKG complete | CPT 93000 | $300.15 |
| EKG tracing only | CPT 93005 | $181.76 |
| EKG interpretation only | CPT 93010 | $35.18 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,056.45 |
| Transthoracic echocardiogram | CPT 93307 | $406.57 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $32,478 |
| COPD w MCC | MS-DRG 190 | $19,646 |
| COPD w CC | MS-DRG 191 | $15,332 |
| COPD w/o CC/MCC | MS-DRG 192 | $12,179 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $15,260 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $11,714 |
| AMI discharged alive w MCC | MS-DRG 280 | $28,436 |
| AMI discharged alive w CC | MS-DRG 281 | $17,748 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $13,519 |
| Heart failure & shock w MCC | MS-DRG 291 | $23,111 |
| Heart failure & shock w CC | MS-DRG 292 | $15,550 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $12,006 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $20,396 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $12,988 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,604.86 |
| GI hemorrhage w CC | MS-DRG 378 | $16,969 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $11,830 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $13,077 |
| Fractures of femur w/o MCC | MS-DRG 533 | $25,062 |
| Kidney/UTI w MCC | MS-DRG 689 | $19,210 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $13,580 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $32,050 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $19,041 |
| Basic metabolic panel (BMP) | CPT 80048 | $20.65 |
| Electrolyte panel | CPT 80051 | $17.11 |
| Comprehensive metabolic panel | CPT 80053 | $25.78 |
| Lipid panel | CPT 80061 | $32.68 |
| Renal function panel | CPT 80069 | $21.18 |
| Hepatic function panel | CPT 80076 | $19.93 |
| Urinalysis automated | CPT 81003 | $5.48 |
| Glucose quantitative | CPT 82947 | $28.62 |
| Hemoglobin A1c | CPT 83036 | $23.72 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $41.01 |
| Complete blood count with automated differential | CPT 85025 | $114.48 |
| Complete blood count without differential | CPT 85027 | $15.79 |
| Urine culture bacterial | CPT 87086 | $19.71 |
| Tissue exam by pathologist level IV | CPT 88305 | $93.52 |
| Fetal non-stress test | CPT 59025 | $179.4 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $5,991.3 |
| Vaginal delivery only | CPT 59409 | $2,433.61 |
| Vaginal delivery with postpartum | CPT 59410 | $3,623.7 |
| Routine obstetric care with C-section | CPT 59510 | $4,831.09 |
| C-section delivery only | CPT 59514 | $3,623.7 |
| C-section with postpartum | CPT 59515 | $4,235 |
| Upper GI endoscopy diagnostic | CPT 43235 | $848.47 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,524.35 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,026.18 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,079.16 |
| Colonoscopy diagnostic | CPT 45378 | $1,568.56 |
| Colonoscopy with biopsy | CPT 45380 | $1,568.56 |
| Colonoscopy with polyp removal | CPT 45385 | $1,406.87 |
| Total shoulder arthroplasty | CPT 23472 | $7,990.68 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $51,114 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $37,278 |
| Hip hemiarthroplasty | CPT 27125 | $4,775 |
| Total hip replacement | CPT 27130 | $11,210 |
| Total knee replacement | CPT 27447 | $11,210 |
| Knee revision arthroplasty single component | CPT 27486 | $3,907 |
| Knee revision arthroplasty all components | CPT 27487 | $4,775 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,697 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $5,781.5 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,982.2 |
| ACL reconstruction | CPT 29888 | $5,781.5 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $64,331 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $43,393 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $29,009 |
| CABG single arterial graft | CPT 33533 | $3,602 |
| CABG 2 arterial grafts | CPT 33534 | $3,602 |
| CABG 3 arterial grafts | CPT 33535 | $4,255.13 |
| CABG 4+ arterial grafts | CPT 33536 | $4,255.13 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $28,660 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $22,442 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $53,498 |
| Open appendectomy | CPT 44950 | $3,285 |
| Laparoscopic appendectomy | CPT 44970 | $5,198.39 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $76,777 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $57,893 |
| Major joint replacement w MCC | MS-DRG 469 | $51,188 |
| Major joint replacement w/o MCC | MS-DRG 470 | $36,247 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,276.37 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,276.37 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $50,288 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $31,995 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $26,482 |
| Open umbilical hernia repair | CPT 49560 | $3,268.65 |
| Umbilical hernia repair age 5+ | CPT 49585 | $2,826 |
| Lap inguinal hernia repair | CPT 49650 | $5,198.39 |
| Lap incisional hernia repair | CPT 49652 | $5,276.37 |
| Total abdominal hysterectomy | CPT 58150 | $3,602 |
| Vaginal hysterectomy | CPT 58260 | $4,530.24 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,328.35 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $6,926.13 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,224.38 |
| OR procedure for obesity w MCC | MS-DRG 619 | $50,523 |
| OR procedure for obesity w CC | MS-DRG 620 | $30,819 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $26,996 |
| Complex cataract surgery | CPT 66982 | $3,147 |
| Cataract surgery with lens implant | CPT 66984 | $3,147 |
| Intravitreal injection | CPT 67028 | $775 |
| Vitrectomy mechanical | CPT 67042 | $4,388.5 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $19,723 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $29,890 |
