| Psychoses | MS-DRG 885 | $26,031 |
| ED visit level 1 | CPT 99281 | $680.34 |
| ED visit level 2 | CPT 99282 | $1,063.03 |
| ED visit level 3 | CPT 99283 | $1,955.96 |
| ED visit level 4 | CPT 99284 | $16,021 |
| ED visit level 5 | CPT 99285 | $19,276 |
| Critical care, first hour | CPT 99291 | $23,131 |
| CT head without contrast | CPT 70450 | $615.46 |
| CT head with contrast | CPT 70460 | $669.57 |
| CT head with and without contrast | CPT 70470 | $723.68 |
| CT neck with contrast | CPT 70491 | $1,177.28 |
| MRI brain without contrast | CPT 70551 | $650.08 |
| MRI brain with contrast | CPT 70552 | $738.04 |
| MRI brain with and without contrast | CPT 70553 | $756.45 |
| Chest X-ray single view | CPT 71045 | $81 |
| Chest X-ray 2 views | CPT 71046 | $341.11 |
| Chest X-ray 3 views | CPT 71047 | $107.54 |
| CT chest without contrast | CPT 71250 | $373.61 |
| CT chest with contrast | CPT 71260 | $1,519.16 |
| CT chest with and without contrast | CPT 71270 | $528.22 |
| MRI chest without contrast | CPT 71550 | $399.83 |
| MRI chest with contrast | CPT 71551 | $501.17 |
| MRI chest with and without contrast | CPT 71552 | $459.9 |
| Lumbosacral spine X-ray | CPT 72100 | $451.79 |
| CT cervical spine without contrast | CPT 72125 | $1,228.2 |
| CT thoracic spine without contrast | CPT 72128 | $391.96 |
| CT lumbar spine without contrast | CPT 72131 | $341.62 |
| MRI cervical spine without contrast | CPT 72141 | $621.04 |
| MRI thoracic spine without contrast | CPT 72146 | $538.84 |
| MRI lumbar spine without contrast | CPT 72148 | $441.66 |
| MRI lumbar spine with and without contrast | CPT 72149 | $519.45 |
| MRI cervical spine with and without contrast | CPT 72156 | $822.76 |
| MRI lumbar spine with contrast | CPT 72158 | $532.42 |
| CT pelvis without contrast | CPT 72192 | $259.09 |
| CT pelvis with contrast | CPT 72193 | $519.8 |
| Shoulder X-ray | CPT 73030 | $340.3 |
| Humerus X-ray | CPT 73060 | $567.83 |
| Hand X-ray 3 views | CPT 73130 | $382.24 |
| MRI upper extremity joint without contrast | CPT 73221 | $425.52 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $808.61 |
| Knee X-ray 1-2 views | CPT 73560 | $102.13 |
| Ankle X-ray 3 views | CPT 73610 | $318.51 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,179.86 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $852.09 |
| CT abdomen without contrast | CPT 74150 | $226.18 |
| CT abdomen with contrast | CPT 74160 | $432.66 |
| CT abdomen with and without contrast | CPT 74170 | $504.33 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,037.24 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,602 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,682.1 |
| MRI abdomen without contrast | CPT 74181 | $368.97 |
| MRI abdomen with and without contrast | CPT 74183 | $537.29 |
| Abdominal ultrasound complete | CPT 76700 | $479.3 |
| Abdominal ultrasound limited | CPT 76705 | $512.12 |
| Retroperitoneal ultrasound complete | CPT 76770 | $136.29 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,029.62 |
| Obstetric ultrasound after first trimester | CPT 76805 | $318.16 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $204.52 |
| Transvaginal ultrasound | CPT 76830 | $565.53 |
| Pelvic ultrasound complete | CPT 76856 | $808.93 |
| Scrotal ultrasound | CPT 76870 | $754.34 |
| Diagnostic mammography unilateral | CPT 77065 | $235.2 |
| Diagnostic mammography bilateral | CPT 77066 | $314.24 |
| Screening mammography bilateral | CPT 77067 | $253.21 |
| EKG tracing only | CPT 93005 | $145.04 |
| Transthoracic echocardiogram complete | CPT 93306 | $688.93 |
| Transthoracic echocardiogram | CPT 93307 | $847.14 |
| Stress echocardiogram | CPT 93350 | $3,211.9 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $37,478 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $18,828 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $12,755 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $29,123 |
| COPD w MCC | MS-DRG 190 | $18,981 |
| COPD w CC | MS-DRG 191 | $14,445 |
| COPD w/o CC/MCC | MS-DRG 192 | $11,001 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $13,323 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $10,390 |
| AMI discharged alive w MCC | MS-DRG 280 | $29,435 |
| AMI discharged alive w CC | MS-DRG 281 | $16,865 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $13,269 |
| Heart failure & shock w MCC | MS-DRG 291 | $23,558 |
| Heart failure & shock w CC | MS-DRG 292 | $15,579 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $10,386 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,289 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,353 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,758.29 |
| GI hemorrhage w CC | MS-DRG 378 | $18,277 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $11,748 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $14,529 |
| Fractures of femur w/o MCC | MS-DRG 533 | $29,216 |
| Kidney/UTI w MCC | MS-DRG 689 | $21,624 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $15,086 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $36,201 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $19,071 |
| Initial hospital care, low complexity | CPT 99221 | $43.41 |
| Initial hospital care, moderate complexity | CPT 99222 | $323.59 |
| Initial hospital care, high complexity | CPT 99223 | $165.81 |
| Basic metabolic panel (BMP) | CPT 80048 | $84.42 |
| General health panel | CPT 80050 | $159.06 |
| Electrolyte panel | CPT 80051 | $24.21 |
| Comprehensive metabolic panel | CPT 80053 | $135.63 |
| Renal function panel | CPT 80069 | $30.45 |
| Hepatic function panel | CPT 80076 | $98.55 |
| Urinalysis non-automated | CPT 81002 | $6.64 |
| Urinalysis automated | CPT 81003 | $12.38 |
| Glucose quantitative | CPT 82947 | $7.97 |
| Hemoglobin A1c | CPT 83036 | $17.68 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $46.47 |
| Complete blood count with automated differential | CPT 85025 | $38.06 |
| Complete blood count without differential | CPT 85027 | $52.46 |
| Tissue exam by pathologist level IV | CPT 88305 | $66.77 |
| Fetal non-stress test | CPT 59025 | $280.3 |
| Vaginal delivery only | CPT 59409 | $14,343 |
| Office visit, established patient, 5 min | CPT 99211 | $59.56 |
| Office visit, established patient, 10-19 min | CPT 99212 | $38.37 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $73.43 |
| Upper GI endoscopy diagnostic | CPT 43235 | $716.7 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,677.92 |
| Sigmoidoscopy diagnostic | CPT 45330 | $428.57 |
| Sigmoidoscopy with biopsy | CPT 45331 | $495.58 |
| Colonoscopy diagnostic | CPT 45378 | $259.33 |
| Colonoscopy with biopsy | CPT 45380 | $960.19 |
| Colonoscopy with polyp removal | CPT 45385 | $846.34 |
| Total shoulder arthroplasty | CPT 23472 | $3,107.08 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,933.01 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,346.78 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,110.36 |
| ACL reconstruction | CPT 29888 | $3,441.35 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $76,964 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $40,139 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $28,178 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $26,572 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $21,454 |
| Laparoscopic appendectomy | CPT 44970 | $38,836 |
| Major joint replacement w MCC | MS-DRG 469 | $40,580 |
| Major joint replacement w/o MCC | MS-DRG 470 | $25,193 |
| Laparoscopic cholecystectomy | CPT 47562 | $8,607.53 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $8,542.89 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $54,275 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $39,034 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $30,396 |
| Lap inguinal hernia repair | CPT 49650 | $1,877.06 |
| Vaginal hysterectomy | CPT 58260 | $3,421.09 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,068 |
| Lap salpingo-oophorectomy | CPT 58661 | $9,711.11 |
| Complex cataract surgery | CPT 66982 | $1,288.31 |
| Cataract surgery with lens implant | CPT 66984 | $1,383.78 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $22,767 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $38,188 |
