| Psychoses | MS-DRG 885 | $14,267 |
| Psychiatric diagnostic evaluation | CPT 90791 | $148.3 |
| ED visit level 1 | CPT 99281 | — |
| ED visit level 2 | CPT 99282 | — |
| ED visit level 3 | CPT 99283 | $349.37 |
| ED visit level 4 | CPT 99284 | $534.03 |
| ED visit level 5 | CPT 99285 | $762.2 |
| Critical care, first hour | CPT 99291 | $1,057.2 |
| CT head without contrast | CPT 70450 | $133.8 |
| CT head with contrast | CPT 70460 | $224.48 |
| CT head with and without contrast | CPT 70470 | $224.48 |
| CT neck with contrast | CPT 70491 | — |
| MRI brain without contrast | CPT 70551 | $305.38 |
| MRI brain with and without contrast | CPT 70553 | $446.5 |
| Chest X-ray single view | CPT 71045 | — |
| Chest X-ray 2 views | CPT 71046 | $111.37 |
| CT chest without contrast | CPT 71250 | $133.8 |
| CT chest with contrast | CPT 71260 | $224.48 |
| CT chest with and without contrast | CPT 71270 | $224.48 |
| Lumbosacral spine X-ray | CPT 72100 | $133.8 |
| CT cervical spine without contrast | CPT 72125 | $133.8 |
| CT thoracic spine without contrast | CPT 72128 | $133.8 |
| CT lumbar spine without contrast | CPT 72131 | — |
| MRI cervical spine without contrast | CPT 72141 | $305.38 |
| MRI thoracic spine without contrast | CPT 72146 | $305.38 |
| MRI lumbar spine without contrast | CPT 72148 | $305.38 |
| MRI lumbar spine with and without contrast | CPT 72149 | $446.5 |
| MRI cervical spine with and without contrast | CPT 72156 | $446.5 |
| MRI lumbar spine with contrast | CPT 72158 | $446.5 |
| CT pelvis without contrast | CPT 72192 | $133.8 |
| CT pelvis with contrast | CPT 72193 | $224.48 |
| Shoulder X-ray | CPT 73030 | — |
| Humerus X-ray | CPT 73060 | $111.37 |
| Hand X-ray 3 views | CPT 73130 | $111.37 |
| MRI upper extremity joint without contrast | CPT 73221 | $305.38 |
| Knee X-ray 1-2 views | CPT 73560 | $111.37 |
| Ankle X-ray 3 views | CPT 73610 | $111.37 |
| MRI lower extremity joint without contrast | CPT 73721 | $305.38 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $446.5 |
| CT abdomen without contrast | CPT 74150 | $133.8 |
| CT abdomen with contrast | CPT 74160 | $224.48 |
| CT abdomen with and without contrast | CPT 74170 | $255.65 |
| CT abdomen and pelvis without contrast | CPT 74176 | — |
| CT abdomen and pelvis with contrast | CPT 74177 | $446.5 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | — |
| MRI abdomen without contrast | CPT 74181 | $305.38 |
| MRI abdomen with and without contrast | CPT 74183 | $446.5 |
| Abdominal ultrasound complete | CPT 76700 | $133.8 |
| Abdominal ultrasound limited | CPT 76705 | — |
| Retroperitoneal ultrasound complete | CPT 76770 | $133.8 |
| Obstetric ultrasound after first trimester | CPT 76805 | $133.8 |
| Transvaginal ultrasound | CPT 76830 | $133.8 |
| Pelvic ultrasound complete | CPT 76856 | — |
| Scrotal ultrasound | CPT 76870 | $133.8 |
| EKG tracing only | CPT 93005 | — |
| Transthoracic echocardiogram | CPT 93307 | — |
| Stress echocardiogram | CPT 93350 | $699.34 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $21,965 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $11,176 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,662.53 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,930 |
| COPD w MCC | MS-DRG 190 | $11,368 |
| COPD w CC | MS-DRG 191 | $9,372.49 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,699.75 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,378 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,673.76 |
| AMI discharged alive w MCC | MS-DRG 280 | $17,578 |
| AMI discharged alive w CC | MS-DRG 281 | $10,193 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,079.77 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,134 |
| Heart failure & shock w CC | MS-DRG 292 | $9,437.18 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,247.69 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,334 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,639.09 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,938.85 |
| GI hemorrhage w CC | MS-DRG 378 | $10,438 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,080.32 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,079.19 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,186 |
| Kidney/UTI w MCC | MS-DRG 689 | $12,794 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,378.94 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,737 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,522 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.5 |
| Electrolyte panel | CPT 80051 | $7.15 |
| Comprehensive metabolic panel | CPT 80053 | $10.56 |
| Lipid panel | CPT 80061 | — |
| Hepatic function panel | CPT 80076 | $8.17 |
| Urinalysis non-automated | CPT 81002 | $3.48 |
| Urinalysis automated | CPT 81003 | $2.25 |
| Glucose quantitative | CPT 82947 | $3.93 |
| Hemoglobin A1c | CPT 83036 | $9.8 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | — |
| Complete blood count with automated differential | CPT 85025 | — |
| Complete blood count without differential | CPT 85027 | $6.55 |
| Urine culture bacterial | CPT 87086 | $30 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $71 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $82.05 |
| Office visit, established patient, 5 min | CPT 99211 | $17.21 |
| Office visit, established patient, 10-19 min | CPT 99212 | $16.37 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $34.43 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $53.79 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,160.81 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,190.22 |
| Colonoscopy diagnostic | CPT 45378 | $1,190.22 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $46,583 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $26,129 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,428 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $18,522 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,009 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $37,018 |
| Major joint replacement w MCC | MS-DRG 469 | $32,986 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,080 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $31,683 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $22,866 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $17,868 |
| Lap inguinal hernia repair | CPT 49650 | $4,338.3 |
| OR procedure for obesity w MCC | MS-DRG 619 | $31,414 |
| OR procedure for obesity w CC | MS-DRG 620 | $17,537 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,547 |
| Cataract surgery with lens implant | CPT 66984 | $2,953.7 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $13,660 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $20,806 |
| Left heart catheterization | CPT 93452 | $4,149.23 |
| Coronary angiography with cath | CPT 93455 | $4,149.23 |
| Coronary angiography with bypass cath | CPT 93458 | $4,149.23 |
