| Psychoses | MS-DRG 885 | $14,085 |
| ED visit level 1 | CPT 99281 | $107.92 |
| ED visit level 2 | CPT 99282 | $196.51 |
| ED visit level 3 | CPT 99283 | $349.37 |
| ED visit level 4 | CPT 99284 | $534.03 |
| ED visit level 5 | CPT 99285 | $762.20 |
| Critical care, first hour | CPT 99291 | $1,057.20 |
| CT head without contrast | CPT 70450 | $133.80 |
| CT head with contrast | CPT 70460 | $224.48 |
| CT head with and without contrast | CPT 70470 | $224.48 |
| CT neck with contrast | CPT 70491 | $224.48 |
| MRI brain without contrast | CPT 70551 | $305.38 |
| MRI brain with contrast | CPT 70552 | $446.50 |
| MRI brain with and without contrast | CPT 70553 | $446.50 |
| Chest X-ray single view | CPT 71045 | $111.37 |
| Chest X-ray 2 views | CPT 71046 | $111.37 |
| CT chest without contrast | CPT 71250 | $133.80 |
| CT chest with contrast | CPT 71260 | $224.48 |
| CT chest with and without contrast | CPT 71270 | $224.48 |
| MRI chest without contrast | CPT 71550 | $305.38 |
| MRI chest with and without contrast | CPT 71552 | $446.50 |
| Lumbosacral spine X-ray | CPT 72100 | $133.80 |
| CT cervical spine without contrast | CPT 72125 | $133.80 |
| CT thoracic spine without contrast | CPT 72128 | $133.80 |
| CT lumbar spine without contrast | CPT 72131 | $133.80 |
| 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 | $446.50 |
| MRI cervical spine with and without contrast | CPT 72156 | $446.50 |
| MRI lumbar spine with contrast | CPT 72158 | $446.50 |
| CT pelvis without contrast | CPT 72192 | $133.80 |
| CT pelvis with contrast | CPT 72193 | $224.48 |
| Shoulder X-ray | CPT 73030 | $111.37 |
| 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 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $446.50 |
| 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 | $446.50 |
| CT abdomen without contrast | CPT 74150 | $133.80 |
| CT abdomen with contrast | CPT 74160 | $224.48 |
| CT abdomen with and without contrast | CPT 74170 | $224.48 |
| CT abdomen and pelvis without contrast | CPT 74176 | $305.38 |
| CT abdomen and pelvis with contrast | CPT 74177 | $446.50 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $446.50 |
| MRI abdomen without contrast | CPT 74181 | $305.38 |
| MRI abdomen with and without contrast | CPT 74183 | $446.50 |
| Abdominal ultrasound complete | CPT 76700 | $133.80 |
| Abdominal ultrasound limited | CPT 76705 | $133.80 |
| Retroperitoneal ultrasound complete | CPT 76770 | $133.80 |
| Obstetric ultrasound first trimester | CPT 76801 | $133.80 |
| Obstetric ultrasound after first trimester | CPT 76805 | $133.80 |
| Transvaginal ultrasound | CPT 76830 | $133.80 |
| Pelvic ultrasound complete | CPT 76856 | $133.80 |
| Scrotal ultrasound | CPT 76870 | $133.80 |
| Diagnostic mammography unilateral | CPT 77065 | $94.37 |
| Diagnostic mammography bilateral | CPT 77066 | $121.01 |
| Screening mammography bilateral | CPT 77067 | $99.86 |
| EKG tracing only | CPT 93005 | $75.50 |
| Transthoracic echocardiogram complete | CPT 93306 | $699.34 |
| Transthoracic echocardiogram | CPT 93307 | $305.38 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $20,003 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,361 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,220.90 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,683 |
| COPD w MCC | MS-DRG 190 | $11,299 |
| COPD w CC | MS-DRG 191 | $8,749.04 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,812.37 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,391.58 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,682.30 |
| AMI discharged alive w MCC | MS-DRG 280 | $16,082 |
| AMI discharged alive w CC | MS-DRG 281 | $9,482.28 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,593.78 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,996 |
| Heart failure & shock w CC | MS-DRG 292 | $8,806.85 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,080.10 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,227 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,715.19 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,081.06 |
| GI hemorrhage w CC | MS-DRG 378 | $10,076 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,700.60 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,138.17 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,732 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,806 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,426.26 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,343 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,486 |
| Hospital discharge, >30 min | CPT 99239 | $79.28 |
| 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 | $3.48 |
| Urinalysis automated | CPT 81003 | $2.25 |
| Glucose quantitative | CPT 82947 | $3.93 |
| Hemoglobin A1c | CPT 83036 | $9.71 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $16.80 |
| 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 | $66.69 |
| Fetal non-stress test | CPT 59025 | $19.62 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $1,994.02 |
| Vaginal delivery only | CPT 59409 | $4,143.08 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | — |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,190.22 |
| Colonoscopy diagnostic | CPT 45378 | — |
| Colonoscopy with biopsy | CPT 45380 | — |
| Colonoscopy with polyp removal | CPT 45385 | — |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $44,915 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $23,724 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,842 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,925 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,786 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,455 |
| Laparoscopic appendectomy | CPT 44970 | $7,737.45 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $97,034 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $53,517 |
| Major joint replacement w MCC | MS-DRG 469 | $29,852 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,212 |
| Laparoscopic cholecystectomy | CPT 47562 | $7,737.45 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,687 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,807 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $16,342 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $7,737.45 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $13,605 |
| Lap salpingo-oophorectomy | CPT 58661 | $7,737.45 |
| OR procedure for obesity w MCC | MS-DRG 619 | $28,447 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,046 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $15,160 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,581 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $20,370 |
| PCI single major coronary artery | CPT 92920 | $7,284.43 |
| PCI with drug-eluting stent | CPT 92928 | $14,775 |
| PCI bypass graft | CPT 92937 | $14,775 |
| 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 |
