| Psychoses | MS-DRG 885 | $10,843 |
| ED visit level 1 | CPT 99281 | $371.28 |
| ED visit level 2 | CPT 99282 | $742.56 |
| ED visit level 3 | CPT 99283 | $1,510.5 |
| ED visit level 4 | CPT 99284 | $17,523 |
| ED visit level 5 | CPT 99285 | $23,236 |
| Critical care, first hour | CPT 99291 | $23,043 |
| CT head without contrast | CPT 70450 | $889.44 |
| CT head with contrast | CPT 70460 | $1,121.51 |
| CT head with and without contrast | CPT 70470 | $1,314.74 |
| CT neck with contrast | CPT 70491 | $1,100.25 |
| MRI brain without contrast | CPT 70551 | $2,405.16 |
| MRI brain with contrast | CPT 70552 | $3,583.69 |
| MRI brain with and without contrast | CPT 70553 | $4,064.73 |
| Chest X-ray single view | CPT 71045 | $29.39 |
| Chest X-ray 2 views | CPT 71046 | $44.56 |
| Chest X-ray 3 views | CPT 71047 | $489.77 |
| CT chest without contrast | CPT 71250 | $1,002.08 |
| CT chest with contrast | CPT 71260 | $1,160.35 |
| CT chest with and without contrast | CPT 71270 | $1,424.46 |
| MRI chest without contrast | CPT 71550 | $1,063.23 |
| MRI chest with contrast | CPT 71551 | $869.19 |
| MRI chest with and without contrast | CPT 71552 | $1,803.17 |
| Lumbosacral spine X-ray | CPT 72100 | $54.04 |
| CT cervical spine without contrast | CPT 72125 | $1,076.84 |
| CT thoracic spine without contrast | CPT 72128 | $1,128.31 |
| CT lumbar spine without contrast | CPT 72131 | $1,128.31 |
| MRI cervical spine without contrast | CPT 72141 | $1,757.19 |
| MRI thoracic spine without contrast | CPT 72146 | $1,757.19 |
| MRI lumbar spine without contrast | CPT 72148 | $2,405.16 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,583.69 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,969.67 |
| MRI lumbar spine with contrast | CPT 72158 | $4,064.73 |
| CT pelvis without contrast | CPT 72192 | $984.6 |
| CT pelvis with contrast | CPT 72193 | $1,115.68 |
| Shoulder X-ray | CPT 73030 | $620.99 |
| Humerus X-ray | CPT 73060 | $46.12 |
| Hand X-ray 3 views | CPT 73130 | $577.49 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,485.54 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,510.57 |
| Knee X-ray 1-2 views | CPT 73560 | $35.68 |
| Ankle X-ray 3 views | CPT 73610 | $443.7 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,485.54 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,510.57 |
| CT abdomen without contrast | CPT 74150 | $1,008.87 |
| CT abdomen with contrast | CPT 74160 | $1,176.86 |
| CT abdomen with and without contrast | CPT 74170 | $1,428.35 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,933.27 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,269.23 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,689.67 |
| MRI abdomen without contrast | CPT 74181 | $1,673.94 |
| MRI abdomen with and without contrast | CPT 74183 | $1,639.09 |
| Abdominal ultrasound complete | CPT 76700 | $695.24 |
| Abdominal ultrasound limited | CPT 76705 | $777.79 |
| Retroperitoneal ultrasound complete | CPT 76770 | $862.37 |
| Obstetric ultrasound first trimester | CPT 76801 | $747.67 |
| Obstetric ultrasound after first trimester | CPT 76805 | $747.67 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $589.85 |
| Transvaginal ultrasound | CPT 76830 | $445.69 |
| Pelvic ultrasound complete | CPT 76856 | $865.81 |
| Scrotal ultrasound | CPT 76870 | $580.77 |
| Diagnostic mammography unilateral | CPT 77065 | $167.17 |
| Diagnostic mammography bilateral | CPT 77066 | $192.28 |
| Screening mammography bilateral | CPT 77067 | $231.43 |
| EKG tracing only | CPT 93005 | $327.1 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,896.6 |
| Transthoracic echocardiogram | CPT 93307 | $806.96 |
| Stress echocardiogram | CPT 93350 | $692.95 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $16,174 |
| COPD w MCC | MS-DRG 190 | $9,850.92 |
| COPD w CC | MS-DRG 191 | $7,740.32 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,090.76 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,564.15 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,828.69 |
| AMI discharged alive w MCC | MS-DRG 280 | $14,254 |
| AMI discharged alive w CC | MS-DRG 281 | $8,169.81 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,358.97 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,753 |
| Heart failure & shock w CC | MS-DRG 292 | $7,845.5 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,720 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,512 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,568.45 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,894.35 |
| GI hemorrhage w CC | MS-DRG 378 | $8,705.34 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,584.15 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,699.92 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,381 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,740.48 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,943.59 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,375 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,954.27 |
| Initial hospital care, low complexity | CPT 99221 | $188.14 |
| Initial hospital care, moderate complexity | CPT 99222 | $259.26 |
| Initial hospital care, high complexity | CPT 99223 | $384.52 |
| Hospital discharge, <30 min | CPT 99238 | $186.63 |
| Hospital discharge, >30 min | CPT 99239 | $273.21 |
| Basic metabolic panel (BMP) | CPT 80048 | $7.37 |
| General health panel | CPT 80050 | $108.75 |
| Electrolyte panel | CPT 80051 | $16.54 |
| Comprehensive metabolic panel | CPT 80053 | $9.2 |
| Lipid panel | CPT 80061 | $49.6 |
| Renal function panel | CPT 80069 | $7.56 |
| Hepatic function panel | CPT 80076 | $355.84 |
| Urinalysis non-automated | CPT 81002 | $33.16 |
| Urinalysis automated | CPT 81003 | $14.8 |
| Glucose quantitative | CPT 82947 | $26.8 |
| Hemoglobin A1c | CPT 83036 | $8.46 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $46.12 |
| Complete blood count with automated differential | CPT 85025 | $18.28 |
| Complete blood count without differential | CPT 85027 | $15.67 |
| Urine culture bacterial | CPT 87086 | $139.92 |
| Urine culture identification | CPT 87088 | $11.94 |
| Tissue exam by pathologist level IV | CPT 88305 | $259.27 |
| Fetal non-stress test | CPT 59025 | $532.45 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $5,073.23 |
| Vaginal delivery only | CPT 59409 | $3,188.09 |
| Routine obstetric care with C-section | CPT 59510 | $5,075.67 |
| C-section delivery only | CPT 59514 | $2,105.74 |
| Office visit, new patient, 15-29 min | CPT 99202 | $297.01 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $437.57 |
| Office visit, new patient, 45-59 min | CPT 99204 | $573 |
| Office visit, new patient, 60-74 min | CPT 99205 | $676.15 |
| Office visit, established patient, 5 min | CPT 99211 | $219.65 |
| Office visit, established patient, 10-19 min | CPT 99212 | $348.58 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $430.71 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $516.66 |
| Office visit, established patient, 40-54 min | CPT 99215 | $615.98 |
| Upper GI endoscopy diagnostic | CPT 43235 | $983.94 |
| Upper GI endoscopy with biopsy | CPT 43239 | $983.94 |
| Sigmoidoscopy diagnostic | CPT 45330 | $964.55 |
| Sigmoidoscopy with biopsy | CPT 45331 | $964.55 |
| Colonoscopy diagnostic | CPT 45378 | $964.55 |
| Colonoscopy with biopsy | CPT 45380 | $1,260.26 |
| Colonoscopy with polyp removal | CPT 45385 | $1,260.26 |
| Total shoulder arthroplasty | CPT 23472 | $14,967 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $27,397 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $17,426 |
| Hip hemiarthroplasty | CPT 27125 | $14,967 |
| Total hip replacement | CPT 27130 | $14,967 |
| Total knee replacement | CPT 27447 | $14,967 |
| Knee revision arthroplasty single component | CPT 27486 | $14,967 |
| Knee revision arthroplasty all components | CPT 27487 | $14,967 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,630.63 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,614.04 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,439.9 |
| ACL reconstruction | CPT 29888 | $7,614.04 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $42,513 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $22,254 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,989 |
| CABG single arterial graft | CPT 33533 | $6,501.35 |
| CABG 2 arterial grafts | CPT 33534 | $7,310.76 |
| CABG 3 arterial grafts | CPT 33535 | $8,118.91 |
| CABG 4+ arterial grafts | CPT 33536 | $8,929.65 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,796 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,528 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $30,801 |
| Open appendectomy | CPT 44950 | $3,868.93 |
| Laparoscopic appendectomy | CPT 44970 | $6,150.16 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $59,004 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $34,470 |
| Major joint replacement w MCC | MS-DRG 469 | $27,035 |
| Major joint replacement w/o MCC | MS-DRG 470 | $16,653 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,150.16 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,150.16 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $26,510 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $18,367 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,434 |
| Open umbilical hernia repair | CPT 49560 | $3,868.93 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,868.93 |
| Lap inguinal hernia repair | CPT 49650 | $6,150.16 |
| Lap incisional hernia repair | CPT 49652 | $6,150.16 |
| Total abdominal hysterectomy | CPT 58150 | $3,134.01 |
| Vaginal hysterectomy | CPT 58260 | $5,359.09 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,150.16 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,826 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,150.16 |
| OR procedure for obesity w MCC | MS-DRG 619 | $26,830 |
| OR procedure for obesity w CC | MS-DRG 620 | $15,436 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $13,992 |
| Complex cataract surgery | CPT 66982 | $2,526.89 |
| Cataract surgery with lens implant | CPT 66984 | $2,526.89 |
| Intravitreal injection | CPT 67028 | $377.67 |
| Vitrectomy mechanical | CPT 67042 | $4,761.39 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,924.55 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $15,724 |
