| Psychoses | MS-DRG 885 | $13,574 |
| ED visit level 1 | CPT 99281 | $518.38 |
| ED visit level 2 | CPT 99282 | $873.02 |
| ED visit level 3 | CPT 99283 | $1,340.84 |
| ED visit level 4 | CPT 99284 | $2,625.08 |
| ED visit level 5 | CPT 99285 | $4,233.79 |
| Critical care, first hour | CPT 99291 | $10,487 |
| CT head without contrast | CPT 70450 | $2,174.43 |
| CT head with contrast | CPT 70460 | $2,444.90 |
| CT head with and without contrast | CPT 70470 | $2,915.45 |
| CT neck with contrast | CPT 70491 | $2,851.44 |
| MRI brain without contrast | CPT 70551 | $1,231.20 |
| Chest X-ray single view | CPT 71045 | $314.68 |
| Chest X-ray 2 views | CPT 71046 | $419.19 |
| Chest X-ray 3 views | CPT 71047 | $497.88 |
| CT chest without contrast | CPT 71250 | $2,402.84 |
| CT chest with contrast | CPT 71260 | $2,943.57 |
| CT chest with and without contrast | CPT 71270 | $3,609.91 |
| Lumbosacral spine X-ray | CPT 72100 | $935.00 |
| CT cervical spine without contrast | CPT 72125 | $2,402.84 |
| CT thoracic spine without contrast | CPT 72128 | $2,402.84 |
| CT lumbar spine without contrast | CPT 72131 | $2,402.84 |
| CT pelvis without contrast | CPT 72192 | $2,234.97 |
| CT pelvis with contrast | CPT 72193 | $2,795.42 |
| Shoulder X-ray | CPT 73030 | $752.25 |
| Humerus X-ray | CPT 73060 | $353.07 |
| Hand X-ray 3 views | CPT 73130 | $735.25 |
| Knee X-ray 1-2 views | CPT 73560 | $698.70 |
| Ankle X-ray 3 views | CPT 73610 | $752.25 |
| CT abdomen without contrast | CPT 74150 | $2,370.79 |
| CT abdomen with contrast | CPT 74160 | $3,199.72 |
| CT abdomen with and without contrast | CPT 74170 | $3,725.82 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,036.13 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,959.54 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,713.85 |
| MRI abdomen with and without contrast | CPT 74183 | $2,060.00 |
| Abdominal ultrasound complete | CPT 76700 | $1,130.16 |
| Abdominal ultrasound limited | CPT 76705 | $918.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $1,130.16 |
| Obstetric ultrasound first trimester | CPT 76801 | $961.99 |
| Obstetric ultrasound after first trimester | CPT 76805 | $1,146.40 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,423.93 |
| Transvaginal ultrasound | CPT 76830 | $1,074.14 |
| Pelvic ultrasound complete | CPT 76856 | $1,070.09 |
| Scrotal ultrasound | CPT 76870 | $1,086.17 |
| EKG tracing only | CPT 93005 | $492.06 |
| Transthoracic echocardiogram complete | CPT 93306 | $3,744.80 |
| Transthoracic echocardiogram | CPT 93307 | $1,800.24 |
| Stress echocardiogram | CPT 93350 | $1,757.54 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $20,126 |
| COPD w MCC | MS-DRG 190 | $12,346 |
| COPD w CC | MS-DRG 191 | $9,758.01 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,730.21 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,538.79 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,409.98 |
| AMI discharged alive w MCC | MS-DRG 280 | $17,523 |
| AMI discharged alive w CC | MS-DRG 281 | $10,256 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,057.97 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,885 |
| Heart failure & shock w CC | MS-DRG 292 | $9,534.49 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,594.35 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,160 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,320.18 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,264.44 |
| GI hemorrhage w CC | MS-DRG 378 | $10,932 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,102.64 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,484.59 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,474 |
| Kidney/UTI w MCC | MS-DRG 689 | $12,229 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,787.64 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $20,374 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,284 |
| Basic metabolic panel (BMP) | CPT 80048 | $87.98 |
| Electrolyte panel | CPT 80051 | $72.90 |
| Comprehensive metabolic panel | CPT 80053 | $173.54 |
| Lipid panel | CPT 80061 | $105.60 |
| Renal function panel | CPT 80069 | $90.34 |
| Hepatic function panel | CPT 80076 | $85.12 |
| Urinalysis non-automated | CPT 81002 | $15.59 |
| Urinalysis automated | CPT 81003 | $28.15 |
| Glucose quantitative | CPT 82947 | $50.11 |
| Hemoglobin A1c | CPT 83036 | $56.93 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $105.25 |
| Complete blood count with automated differential | CPT 85025 | $81.07 |
| Complete blood count without differential | CPT 85027 | $67.45 |
| Urine culture bacterial | CPT 87086 | $84.14 |
| Urine culture identification | CPT 87088 | $84.33 |
| Tissue exam by pathologist level IV | CPT 88305 | $82.62 |
| Fetal non-stress test | CPT 59025 | $463.25 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $9,407.93 |
| Vaginal delivery only | CPT 59409 | $7,470.00 |
| Vaginal delivery with postpartum | CPT 59410 | $9,407.93 |
| Routine obstetric care with C-section | CPT 59510 | $9,468.00 |
| C-section delivery only | CPT 59514 | $9,468.00 |
| C-section with postpartum | CPT 59515 | $13,227 |
| Office visit, new patient, 15-29 min | CPT 99202 | $1,568.25 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $1,959.25 |
| Office visit, new patient, 45-59 min | CPT 99204 | $142.50 |
| Office visit, new patient, 60-74 min | CPT 99205 | $3,715.35 |
| Office visit, established patient, 5 min | CPT 99211 | $1,175.55 |
| Office visit, established patient, 10-19 min | CPT 99212 | $673.63 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $187.85 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $2,446.30 |
| Office visit, established patient, 40-54 min | CPT 99215 | $235.45 |
| Upper GI endoscopy diagnostic | CPT 43235 | $5,603.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $6,729.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $5,446.65 |
| Sigmoidoscopy with biopsy | CPT 45331 | $5,446.65 |
| Colonoscopy diagnostic | CPT 45378 | $5,603.00 |
| Colonoscopy with biopsy | CPT 45380 | $5,603.00 |
| Colonoscopy with polyp removal | CPT 45385 | $5,603.00 |
| Total shoulder arthroplasty | CPT 23472 | $18,477 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $54,536 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $49,768 |
| Hip hemiarthroplasty | CPT 27125 | $9,407.93 |
| Total hip replacement | CPT 27130 | $18,477 |
| Total knee replacement | CPT 27447 | $19,342 |
| Knee revision arthroplasty single component | CPT 27486 | $11,647 |
| Knee revision arthroplasty all components | CPT 27487 | $11,660 |
| Shoulder arthroscopy with decompression | CPT 29826 | $10,091 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $13,256 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $9,945.00 |
| ACL reconstruction | CPT 29888 | $10,277 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $52,763 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $27,650 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,636 |
| CABG single arterial graft | CPT 33533 | $8,226.00 |
| CABG 2 arterial grafts | CPT 33534 | $8,226.00 |
| CABG 3 arterial grafts | CPT 33535 | $8,226.00 |
| CABG 4+ arterial grafts | CPT 33536 | $8,226.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $18,405 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $14,390 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $38,044 |
| Open appendectomy | CPT 44950 | $7,030.11 |
| Laparoscopic appendectomy | CPT 44970 | $13,456 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $72,614 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $42,495 |
| Major joint replacement w MCC | MS-DRG 469 | $33,417 |
| Major joint replacement w/o MCC | MS-DRG 470 | $20,676 |
| Laparoscopic cholecystectomy | CPT 47562 | $16,260 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $16,260 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $32,771 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $22,780 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $17,941 |
| Open umbilical hernia repair | CPT 49560 | $9,945.00 |
| Umbilical hernia repair age 5+ | CPT 49585 | $9,945.00 |
| Lap inguinal hernia repair | CPT 49650 | $10,301 |
| Lap incisional hernia repair | CPT 49652 | $13,456 |
| Total abdominal hysterectomy | CPT 58150 | $8,409.00 |
| Vaginal hysterectomy | CPT 58260 | $7,030.11 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $18,491 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $18,109 |
| Lap salpingo-oophorectomy | CPT 58661 | $13,256 |
| OR procedure for obesity w MCC | MS-DRG 619 | $33,157 |
| OR procedure for obesity w CC | MS-DRG 620 | $19,197 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $17,418 |
| Complex cataract surgery | CPT 66982 | $9,843.54 |
| Cataract surgery with lens implant | CPT 66984 | $9,843.54 |
| Intravitreal injection | CPT 67028 | $3,738.00 |
| Vitrectomy mechanical | CPT 67042 | $9,429.41 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,428 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $19,549 |
| PCI single major coronary artery | CPT 92920 | $9,006.60 |
| PCI with drug-eluting stent | CPT 92928 | $12,141 |
| PCI bypass graft | CPT 92937 | $15,179 |
| Left heart catheterization | CPT 93452 | $13,867 |
| Coronary angiography with cath | CPT 93455 | $15,086 |
| Coronary angiography with bypass cath | CPT 93458 | $17,333 |
