| Psychoses | MS-DRG 885 | $12,009 |
| ED visit level 1 | CPT 99281 | $409.82 |
| ED visit level 2 | CPT 99282 | $573.34 |
| ED visit level 3 | CPT 99283 | $941.08 |
| ED visit level 4 | CPT 99284 | $1,596.84 |
| ED visit level 5 | CPT 99285 | $2,236.92 |
| Critical care, first hour | CPT 99291 | $4,258.80 |
| CT head without contrast | CPT 70450 | $1,984.33 |
| CT head with contrast | CPT 70460 | $3,349.08 |
| CT head with and without contrast | CPT 70470 | $3,650.85 |
| CT neck with contrast | CPT 70491 | $3,208.13 |
| MRI brain without contrast | CPT 70551 | $4,705.26 |
| MRI brain with contrast | CPT 70552 | $5,562.27 |
| MRI brain with and without contrast | CPT 70553 | $6,367.20 |
| Chest X-ray single view | CPT 71045 | $372.65 |
| Chest X-ray 2 views | CPT 71046 | $597.24 |
| Chest X-ray 3 views | CPT 71047 | $736.47 |
| CT chest without contrast | CPT 71250 | $3,731.28 |
| CT chest with contrast | CPT 71260 | $3,100.44 |
| CT chest with and without contrast | CPT 71270 | $3,614.94 |
| MRI chest without contrast | CPT 71550 | $2,387.00 |
| MRI chest with contrast | CPT 71551 | $3,384.99 |
| MRI chest with and without contrast | CPT 71552 | $3,741.57 |
| Lumbosacral spine X-ray | CPT 72100 | $489.77 |
| CT cervical spine without contrast | CPT 72125 | $3,735.90 |
| CT thoracic spine without contrast | CPT 72128 | $3,675.42 |
| CT lumbar spine without contrast | CPT 72131 | $3,992.94 |
| MRI cervical spine without contrast | CPT 72141 | $3,731.28 |
| MRI thoracic spine without contrast | CPT 72146 | $3,731.28 |
| MRI lumbar spine without contrast | CPT 72148 | $3,731.28 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,711.33 |
| MRI cervical spine with and without contrast | CPT 72156 | $4,819.92 |
| MRI lumbar spine with contrast | CPT 72158 | $4,819.92 |
| CT pelvis without contrast | CPT 72192 | $2,476.53 |
| CT pelvis with contrast | CPT 72193 | $2,860.13 |
| Shoulder X-ray | CPT 73030 | $513.24 |
| Humerus X-ray | CPT 73060 | $513.24 |
| Hand X-ray 3 views | CPT 73130 | $612.78 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,684.66 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $4,865.70 |
| Knee X-ray 1-2 views | CPT 73560 | $761.46 |
| Ankle X-ray 3 views | CPT 73610 | $761.46 |
| MRI lower extremity joint without contrast | CPT 73721 | $4,025.70 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,860.24 |
| CT abdomen without contrast | CPT 74150 | $2,917.32 |
| CT abdomen with contrast | CPT 74160 | $3,033.45 |
| CT abdomen with and without contrast | CPT 74170 | $3,063.85 |
| CT abdomen and pelvis without contrast | CPT 74176 | $4,943.05 |
| CT abdomen and pelvis with contrast | CPT 74177 | $5,219.55 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $5,419.26 |
| MRI abdomen without contrast | CPT 74181 | $2,942.73 |
| MRI abdomen with and without contrast | CPT 74183 | $4,033.89 |
| Abdominal ultrasound complete | CPT 76700 | $1,362.69 |
| Abdominal ultrasound limited | CPT 76705 | $567.60 |
| Retroperitoneal ultrasound complete | CPT 76770 | $1,106.60 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,165.82 |
| Obstetric ultrasound after first trimester | CPT 76805 | $995.45 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,815.94 |
| Transvaginal ultrasound | CPT 76830 | $970.52 |
| Pelvic ultrasound complete | CPT 76856 | $1,005.80 |
| Scrotal ultrasound | CPT 76870 | $1,035.09 |
| Diagnostic mammography unilateral | CPT 77065 | $667.00 |
| Diagnostic mammography bilateral | CPT 77066 | $833.98 |
| Screening mammography bilateral | CPT 77067 | $779.24 |
| EKG tracing only | CPT 93005 | $198.13 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,014.11 |
| Transthoracic echocardiogram | CPT 93307 | $1,098.09 |
| Stress echocardiogram | CPT 93350 | $795.49 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $17,707 |
| COPD w MCC | MS-DRG 190 | $10,940 |
| COPD w CC | MS-DRG 191 | $8,689.82 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,926.22 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,499.16 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,647.71 |
| AMI discharged alive w MCC | MS-DRG 280 | $15,443 |
| AMI discharged alive w CC | MS-DRG 281 | $9,122.54 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,211.28 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,279 |
| Heart failure & shock w CC | MS-DRG 292 | $8,495.42 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,938.35 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,649 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,439.32 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,651.42 |
| GI hemorrhage w CC | MS-DRG 378 | $9,710.40 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,380.41 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,582.31 |
| Fractures of femur w/o MCC | MS-DRG 533 | $13,661 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,838 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,845.87 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $17,923 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,017 |
| Basic metabolic panel (BMP) | CPT 80048 | $257.47 |
| General health panel | CPT 80050 | $1,061.48 |
| Electrolyte panel | CPT 80051 | $143.08 |
| Comprehensive metabolic panel | CPT 80053 | $11.00 |
| Lipid panel | CPT 80061 | $83.60 |
| Renal function panel | CPT 80069 | $38.70 |
| Hepatic function panel | CPT 80076 | $244.68 |
| Urinalysis non-automated | CPT 81002 | $61.83 |
| Urinalysis automated | CPT 81003 | $197.58 |
| Glucose quantitative | CPT 82947 | $36.22 |
| Hemoglobin A1c | CPT 83036 | $8.52 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $228.47 |
| Complete blood count with automated differential | CPT 85025 | $34.65 |
| Complete blood count without differential | CPT 85027 | $118.05 |
| Urine culture identification | CPT 87088 | $149.61 |
| Tissue exam by pathologist level IV | CPT 88305 | $32.90 |
| Fetal non-stress test | CPT 59025 | $596.43 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $7,139.82 |
| Vaginal delivery only | CPT 59409 | $4,258.00 |
| Vaginal delivery with postpartum | CPT 59410 | $7,685.41 |
| Routine obstetric care with C-section | CPT 59510 | $8,159.80 |
| C-section delivery only | CPT 59514 | $8,159.80 |
| C-section with postpartum | CPT 59515 | $8,974.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | $267.12 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $304.80 |
| Office visit, new patient, 45-59 min | CPT 99204 | $420.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $550.21 |
| Office visit, established patient, 5 min | CPT 99211 | $196.63 |
| Office visit, established patient, 10-19 min | CPT 99212 | $238.22 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $276.42 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $371.28 |
| Office visit, established patient, 40-54 min | CPT 99215 | $457.17 |
| Upper GI endoscopy diagnostic | CPT 43235 | $3,137.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $3,137.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $2,802.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,802.00 |
| Colonoscopy diagnostic | CPT 45378 | $3,137.00 |
| Colonoscopy with biopsy | CPT 45380 | $3,137.00 |
| Colonoscopy with polyp removal | CPT 45385 | $3,137.00 |
| Total shoulder arthroplasty | CPT 23472 | $14,821 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $29,625 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $18,867 |
| Hip hemiarthroplasty | CPT 27125 | $7,491.91 |
| Total hip replacement | CPT 27130 | $11,993 |
| Total knee replacement | CPT 27447 | $14,994 |
| Knee revision arthroplasty single component | CPT 27486 | $9,495.00 |
| Knee revision arthroplasty all components | CPT 27487 | $9,495.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $6,617.00 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $8,078.96 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $5,537.50 |
| ACL reconstruction | CPT 29888 | $8,078.96 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $46,092 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $24,251 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,412 |
| CABG single arterial graft | CPT 33533 | $11,611 |
| CABG 2 arterial grafts | CPT 33534 | $13,555 |
| CABG 3 arterial grafts | CPT 33535 | $13,555 |
| CABG 4+ arterial grafts | CPT 33536 | $13,555 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,211 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,718 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,290 |
| Open appendectomy | CPT 44950 | $4,719.46 |
| Laparoscopic appendectomy | CPT 44970 | $6,842.69 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $63,357 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $37,162 |
| Major joint replacement w MCC | MS-DRG 469 | $29,266 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,185 |
| Laparoscopic cholecystectomy | CPT 47562 | $8,076.00 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $8,076.00 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,704 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,015 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,807 |
| Open umbilical hernia repair | CPT 49560 | $5,537.50 |
| Umbilical hernia repair age 5+ | CPT 49585 | $5,537.50 |
| Lap inguinal hernia repair | CPT 49650 | $7,348.39 |
| Lap incisional hernia repair | CPT 49652 | $8,014.50 |
| Total abdominal hysterectomy | CPT 58150 | $6,691.00 |
| Vaginal hysterectomy | CPT 58260 | $5,687.55 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $8,076.00 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $11,488 |
| Lap salpingo-oophorectomy | CPT 58661 | $7,817.32 |
| OR procedure for obesity w MCC | MS-DRG 619 | $29,040 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,899 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $15,352 |
| Complex cataract surgery | CPT 66982 | $4,258.00 |
| Cataract surgery with lens implant | CPT 66984 | $4,258.00 |
| Intravitreal injection | CPT 67028 | $2,240.00 |
| Vitrectomy mechanical | CPT 67042 | $6,020.45 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,012 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $17,205 |
| PCI single major coronary artery | CPT 92920 | $8,719.00 |
| PCI with drug-eluting stent | CPT 92928 | $12,956 |
| PCI bypass graft | CPT 92937 | $12,956 |
| Left heart catheterization | CPT 93452 | $9,920.26 |
| Coronary angiography with cath | CPT 93455 | $10,811 |
| Coronary angiography with bypass cath | CPT 93458 | $11,117 |
