| Psychoses | MS-DRG 885 | $12,244 |
| ED visit level 1 | CPT 99281 | $75.93 |
| ED visit level 2 | CPT 99282 | $136.55 |
| ED visit level 3 | CPT 99283 | $238.76 |
| ED visit level 4 | CPT 99284 | $367.19 |
| ED visit level 5 | CPT 99285 | $3,268.23 |
| Critical care, first hour | CPT 99291 | $178.71 |
| CT head without contrast | CPT 70450 | $91.7 |
| CT head with contrast | CPT 70460 | $153.51 |
| CT head with and without contrast | CPT 70470 | $153.51 |
| CT neck with contrast | CPT 70491 | $153.51 |
| MRI brain without contrast | CPT 70551 | $208.44 |
| MRI brain with contrast | CPT 70552 | $307.95 |
| MRI brain with and without contrast | CPT 70553 | $307.95 |
| Chest X-ray single view | CPT 71045 | $75.93 |
| Chest X-ray 2 views | CPT 71046 | $75.93 |
| Chest X-ray 3 views | CPT 71047 | $75.93 |
| CT chest without contrast | CPT 71250 | $91.7 |
| CT chest with contrast | CPT 71260 | $153.51 |
| CT chest with and without contrast | CPT 71270 | $153.51 |
| MRI chest without contrast | CPT 71550 | $208.44 |
| MRI chest with contrast | CPT 71551 | $681.27 |
| Lumbosacral spine X-ray | CPT 72100 | $91.7 |
| CT cervical spine without contrast | CPT 72125 | $91.7 |
| CT thoracic spine without contrast | CPT 72128 | $91.7 |
| CT lumbar spine without contrast | CPT 72131 | $91.7 |
| MRI cervical spine without contrast | CPT 72141 | $208.44 |
| MRI thoracic spine without contrast | CPT 72146 | $208.44 |
| MRI lumbar spine without contrast | CPT 72148 | $208.44 |
| MRI lumbar spine with and without contrast | CPT 72149 | $307.95 |
| MRI cervical spine with and without contrast | CPT 72156 | $307.95 |
| MRI lumbar spine with contrast | CPT 72158 | $307.95 |
| CT pelvis without contrast | CPT 72192 | $91.7 |
| CT pelvis with contrast | CPT 72193 | $153.51 |
| Shoulder X-ray | CPT 73030 | $330.08 |
| Humerus X-ray | CPT 73060 | $319.95 |
| Hand X-ray 3 views | CPT 73130 | $330.89 |
| MRI upper extremity joint without contrast | CPT 73221 | $208.44 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $307.95 |
| Knee X-ray 1-2 views | CPT 73560 | $311.33 |
| Ankle X-ray 3 views | CPT 73610 | $361.05 |
| MRI lower extremity joint without contrast | CPT 73721 | $4,029.79 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $307.95 |
| CT abdomen without contrast | CPT 74150 | $91.7 |
| CT abdomen with contrast | CPT 74160 | $153.51 |
| CT abdomen with and without contrast | CPT 74170 | $153.51 |
| CT abdomen and pelvis without contrast | CPT 74176 | $208.44 |
| CT abdomen and pelvis with contrast | CPT 74177 | $307.95 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $307.95 |
| MRI abdomen without contrast | CPT 74181 | $208.44 |
| MRI abdomen with and without contrast | CPT 74183 | $307.95 |
| Abdominal ultrasound complete | CPT 76700 | $91.7 |
| Abdominal ultrasound limited | CPT 76705 | $91.7 |
| Obstetric ultrasound first trimester | CPT 76801 | $91.7 |
| Obstetric ultrasound after first trimester | CPT 76805 | $40.49 |
| Transvaginal ultrasound | CPT 76830 | $91.7 |
| Pelvic ultrasound complete | CPT 76856 | $91.7 |
| Scrotal ultrasound | CPT 76870 | $91.7 |
| Diagnostic mammography unilateral | CPT 77065 | $32.64 |
| Diagnostic mammography bilateral | CPT 77066 | $98.3 |
| Screening mammography bilateral | CPT 77067 | $30.58 |
| EKG complete | CPT 93000 | $194.79 |
| EKG tracing only | CPT 93005 | $84.53 |
| EKG interpretation only | CPT 93010 | $38.42 |
| Transthoracic echocardiogram complete | CPT 93306 | $472.8 |
| Transthoracic echocardiogram | CPT 93307 | $36.89 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,698 |
| COPD w MCC | MS-DRG 190 | $9,709.73 |
| COPD w CC | MS-DRG 191 | $7,389.46 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,627.56 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,064.25 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,509.22 |
| AMI discharged alive w MCC | MS-DRG 280 | $14,061 |
| AMI discharged alive w CC | MS-DRG 281 | $8,056.53 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,338.46 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,253 |
| Heart failure & shock w CC | MS-DRG 292 | $7,442.05 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,554 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,448.9 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,962.25 |
| GI hemorrhage w CC | MS-DRG 378 | $8,596.49 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,525.88 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,833.72 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,171 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,095.81 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $17,027 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,969.91 |
| Initial hospital care, low complexity | CPT 99221 | $67.66 |
| Initial hospital care, moderate complexity | CPT 99222 | $106.06 |
| Initial hospital care, high complexity | CPT 99223 | $141.71 |
| Hospital discharge, <30 min | CPT 99238 | $66.51 |
| Hospital discharge, >30 min | CPT 99239 | $94.39 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.46 |
| Electrolyte panel | CPT 80051 | $7.01 |
| Comprehensive metabolic panel | CPT 80053 | $10.56 |
| Lipid panel | CPT 80061 | $13.39 |
| Renal function panel | CPT 80069 | $8.68 |
| Hepatic function panel | CPT 80076 | $8.17 |
| Urinalysis non-automated | CPT 81002 | $48.9 |
| Urinalysis automated | CPT 81003 | $11.25 |
| Glucose quantitative | CPT 82947 | $3.93 |
| Hemoglobin A1c | CPT 83036 | $109.21 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $16.8 |
| Complete blood count with automated differential | CPT 85025 | $7.77 |
| Complete blood count without differential | CPT 85027 | $6.47 |
| Urine culture bacterial | CPT 87086 | $8.07 |
| Tissue exam by pathologist level IV | CPT 88305 | $46.07 |
| Office visit, new patient, 15-29 min | CPT 99202 | $60.04 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $87.21 |
| Office visit, new patient, 45-59 min | CPT 99204 | $129.06 |
| Office visit, new patient, 60-74 min | CPT 99205 | $170.73 |
| Office visit, established patient, 5 min | CPT 99211 | — |
| Office visit, established patient, 10-19 min | CPT 99212 | $60.04 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $65.13 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $84.45 |
| Office visit, established patient, 40-54 min | CPT 99215 | $122.24 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $40,291 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $21,013 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,752 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,828 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,972 |
| Major joint replacement w MCC | MS-DRG 469 | $26,588 |
| Major joint replacement w/o MCC | MS-DRG 470 | $16,908 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $25,528 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $18,360 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,297 |
| Total abdominal hysterectomy | CPT 58150 | $838.68 |
| Vaginal hysterectomy | CPT 58260 | $677.65 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $716.96 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $798.97 |
| Lap salpingo-oophorectomy | CPT 58661 | $424.44 |
| PCI single major coronary artery | CPT 92920 | $4,916.44 |
| PCI with drug-eluting stent | CPT 92928 | $9,779.02 |
| PCI bypass graft | CPT 92937 | $9,779.02 |
| Coronary angiography with cath | CPT 93455 | $2,773.52 |
| Coronary angiography with bypass cath | CPT 93458 | $2,773.52 |
