| Psychoses | MS-DRG 885 | $10,560 |
| ED visit level 1 | CPT 99281 | $226.29 |
| ED visit level 2 | CPT 99282 | $660.63 |
| ED visit level 3 | CPT 99283 | $878.94 |
| ED visit level 4 | CPT 99284 | $1,401.63 |
| ED visit level 5 | CPT 99285 | $3,194.85 |
| Critical care, first hour | CPT 99291 | $4,736.9 |
| CT head without contrast | CPT 70450 | $191.38 |
| CT head with contrast | CPT 70460 | $289.34 |
| CT head with and without contrast | CPT 70470 | $315.88 |
| CT neck with contrast | CPT 70491 | $335.43 |
| MRI brain without contrast | CPT 70551 | $382.79 |
| MRI brain with contrast | CPT 70552 | $572.5 |
| MRI brain with and without contrast | CPT 70553 | $621.7 |
| Chest X-ray single view | CPT 71045 | $102.04 |
| Chest X-ray 2 views | CPT 71046 | $102.04 |
| Chest X-ray 3 views | CPT 71047 | $103.69 |
| CT chest without contrast | CPT 71250 | $239.27 |
| CT chest with contrast | CPT 71260 | $314.25 |
| CT chest with and without contrast | CPT 71270 | $375.37 |
| MRI chest without contrast | CPT 71550 | $530.1 |
| MRI chest with contrast | CPT 71551 | $922.84 |
| MRI chest with and without contrast | CPT 71552 | $645.24 |
| Lumbosacral spine X-ray | CPT 72100 | $138.17 |
| CT cervical spine without contrast | CPT 72125 | $242.01 |
| CT thoracic spine without contrast | CPT 72128 | $239.33 |
| CT lumbar spine without contrast | CPT 72131 | $238.62 |
| MRI cervical spine without contrast | CPT 72141 | $378.45 |
| MRI thoracic spine without contrast | CPT 72146 | $5,814.76 |
| MRI lumbar spine without contrast | CPT 72148 | $378.76 |
| MRI lumbar spine with and without contrast | CPT 72149 | $574.74 |
| MRI cervical spine with and without contrast | CPT 72156 | $624.89 |
| MRI lumbar spine with contrast | CPT 72158 | $624.25 |
| CT pelvis without contrast | CPT 72192 | $216.84 |
| CT pelvis with contrast | CPT 72193 | $347.5 |
| Shoulder X-ray | CPT 73030 | $96.26 |
| Humerus X-ray | CPT 73060 | $96.26 |
| Hand X-ray 3 views | CPT 73130 | $96.26 |
| MRI upper extremity joint without contrast | CPT 73221 | $390.9 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,593.85 |
| Knee X-ray 1-2 views | CPT 73560 | $96.26 |
| Ankle X-ray 3 views | CPT 73610 | $96.26 |
| MRI lower extremity joint without contrast | CPT 73721 | $390.27 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $579.88 |
| CT abdomen without contrast | CPT 74150 | $218.89 |
| CT abdomen with contrast | CPT 74160 | $350.6 |
| CT abdomen with and without contrast | CPT 74170 | $371.31 |
| CT abdomen and pelvis without contrast | CPT 74176 | $333.04 |
| CT abdomen and pelvis with contrast | CPT 74177 | $532.88 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $532.88 |
| MRI abdomen without contrast | CPT 74181 | $416.67 |
| MRI abdomen with and without contrast | CPT 74183 | $541.09 |
| Abdominal ultrasound complete | CPT 76700 | $175.6 |
| Abdominal ultrasound limited | CPT 76705 | $245.18 |
| Retroperitoneal ultrasound complete | CPT 76770 | $175.6 |
| Obstetric ultrasound first trimester | CPT 76801 | $175.6 |
| Obstetric ultrasound after first trimester | CPT 76805 | $317.93 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $272.89 |
| Transvaginal ultrasound | CPT 76830 | $175.6 |
| Pelvic ultrasound complete | CPT 76856 | $175.6 |
| Scrotal ultrasound | CPT 76870 | $175.6 |
| Diagnostic mammography unilateral | CPT 77065 | $173.18 |
| Diagnostic mammography bilateral | CPT 77066 | $597.8 |
| Screening mammography bilateral | CPT 77067 | $555.95 |
| EKG tracing only | CPT 93005 | $96.58 |
| Transthoracic echocardiogram complete | CPT 93306 | $3,521.81 |
| Transthoracic echocardiogram | CPT 93307 | $865.6 |
| Stress echocardiogram | CPT 93350 | $618.92 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,572 |
| COPD w MCC | MS-DRG 190 | $9,620.11 |
| COPD w CC | MS-DRG 191 | $7,640.66 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,089.49 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,472.97 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,844.53 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,581 |
| AMI discharged alive w CC | MS-DRG 281 | $8,021.26 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,340.21 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,797 |
| Heart failure & shock w CC | MS-DRG 292 | $7,469.68 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,220.61 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,243 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,540.79 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,968.24 |
| GI hemorrhage w CC | MS-DRG 378 | $8,538.32 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,609.43 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,666.56 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,013 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,530.51 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,898.37 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,761 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,807.94 |
| Basic metabolic panel (BMP) | CPT 80048 | $529.98 |
| Electrolyte panel | CPT 80051 | $489.83 |
| Comprehensive metabolic panel | CPT 80053 | $654.81 |
| Lipid panel | CPT 80061 | $443.11 |
| Renal function panel | CPT 80069 | $654.81 |
| Hepatic function panel | CPT 80076 | $540.93 |
| Urinalysis non-automated | CPT 81002 | $59.13 |
| Urinalysis automated | CPT 81003 | $53.29 |
| Glucose quantitative | CPT 82947 | $341.64 |
| Hemoglobin A1c | CPT 83036 | $5 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $226.98 |
| Complete blood count with automated differential | CPT 85025 | $306.6 |
| Complete blood count without differential | CPT 85027 | $327.04 |
| Urine culture bacterial | CPT 87086 | $183.96 |
| Urine culture identification | CPT 87088 | $143.08 |
| Tissue exam by pathologist level IV | CPT 88305 | $104.1 |
| Fetal non-stress test | CPT 59025 | $271.52 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $4,954.48 |
| Vaginal delivery only | CPT 59409 | $3,290.91 |
| Vaginal delivery with postpartum | CPT 59410 | $5,427 |
| Routine obstetric care with C-section | CPT 59510 | $4,955.87 |
| C-section delivery only | CPT 59514 | $3,122.87 |
| C-section with postpartum | CPT 59515 | $7,239.26 |
| Office visit, new patient, 15-29 min | CPT 99202 | $191.48 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $215.84 |
| Office visit, new patient, 45-59 min | CPT 99204 | $253 |
| Office visit, new patient, 60-74 min | CPT 99205 | $282 |
| Office visit, established patient, 5 min | CPT 99211 | $81.91 |
| Office visit, established patient, 10-19 min | CPT 99212 | $110.58 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $151.9 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $152.38 |
| Office visit, established patient, 40-54 min | CPT 99215 | $225 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,037.66 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,037.66 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,001.02 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,001.02 |
| Colonoscopy diagnostic | CPT 45378 | $1,254.99 |
| Colonoscopy with biopsy | CPT 45380 | $1,403.8 |
| Colonoscopy with polyp removal | CPT 45385 | $1,672.53 |
| Total shoulder arthroplasty | CPT 23472 | $14,624 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $26,054 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $16,592 |
| Hip hemiarthroplasty | CPT 27125 | $6,807 |
| Total hip replacement | CPT 27130 | $11,757 |
| Total knee replacement | CPT 27447 | $13,774 |
| Knee revision arthroplasty single component | CPT 27486 | $12,093 |
| Knee revision arthroplasty all components | CPT 27487 | $8,217.22 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,761.05 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,453.71 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,572.23 |
| ACL reconstruction | CPT 29888 | $7,428.38 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $40,537 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $21,327 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,432 |
| CABG single arterial graft | CPT 33533 | $9,054 |
| CABG 2 arterial grafts | CPT 33534 | $10,515 |
| CABG 3 arterial grafts | CPT 33535 | $10,770 |
| CABG 4+ arterial grafts | CPT 33536 | $11,266 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,256 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,184 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $29,278 |
| Open appendectomy | CPT 44950 | $3,786.08 |
| Laparoscopic appendectomy | CPT 44970 | $6,000.82 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $55,723 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $32,683 |
| Major joint replacement w MCC | MS-DRG 469 | $25,738 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,992 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,382.57 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,382.57 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $25,244 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $17,602 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,900 |
| Open umbilical hernia repair | CPT 49560 | $4,013.24 |
| Umbilical hernia repair age 5+ | CPT 49585 | $4,013.24 |
| Lap inguinal hernia repair | CPT 49650 | $6,021.29 |
| Lap incisional hernia repair | CPT 49652 | $6,062 |
| Total abdominal hysterectomy | CPT 58150 | $5,934.56 |
| Vaginal hysterectomy | CPT 58260 | $5,247.38 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,382.57 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,563 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,021.29 |
| OR procedure for obesity w MCC | MS-DRG 619 | $25,540 |
| OR procedure for obesity w CC | MS-DRG 620 | $14,861 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $13,500 |
| Complex cataract surgery | CPT 66982 | $2,990.02 |
| Cataract surgery with lens implant | CPT 66984 | $3,349.39 |
| Intravitreal injection | CPT 67028 | $915.5 |
| Vitrectomy mechanical | CPT 67042 | $4,660.24 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,683.4 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $15,130 |
| PCI single major coronary artery | CPT 92920 | $6,353.17 |
| PCI with drug-eluting stent | CPT 92928 | $11,912 |
| PCI bypass graft | CPT 92937 | $11,912 |
| Left heart catheterization | CPT 93452 | $4,677.01 |
| Coronary angiography with cath | CPT 93455 | $4,677.01 |
| Coronary angiography with bypass cath | CPT 93458 | $4,677.01 |
