| ED visit level 1 | CPT 99281 | $255.58 |
| ED visit level 2 | CPT 99282 | $462.82 |
| ED visit level 3 | CPT 99283 | $815.41 |
| ED visit level 4 | CPT 99284 | $1,281.74 |
| ED visit level 5 | CPT 99285 | $1,838.85 |
| Critical care, first hour | CPT 99291 | $2,624.55 |
| CT head without contrast | CPT 70450 | $1,605.75 |
| CT head with contrast | CPT 70460 | $616.00 |
| CT head with and without contrast | CPT 70470 | $3,729.75 |
| CT neck with contrast | CPT 70491 | $1,107.75 |
| MRI brain without contrast | CPT 70551 | $6,161.25 |
| MRI brain with contrast | CPT 70552 | $1,270.01 |
| MRI brain with and without contrast | CPT 70553 | $4,977.00 |
| Chest X-ray single view | CPT 71045 | $586.50 |
| Chest X-ray 2 views | CPT 71046 | $306.00 |
| Chest X-ray 3 views | CPT 71047 | $279.11 |
| CT chest without contrast | CPT 71250 | $1,658.25 |
| CT chest with contrast | CPT 71260 | $2,254.50 |
| CT chest with and without contrast | CPT 71270 | $616.00 |
| MRI chest without contrast | CPT 71550 | $793.95 |
| MRI chest with and without contrast | CPT 71552 | $1,270.01 |
| Lumbosacral spine X-ray | CPT 72100 | $276.75 |
| CT cervical spine without contrast | CPT 72125 | $4,298.25 |
| CT thoracic spine without contrast | CPT 72128 | $375.95 |
| CT lumbar spine without contrast | CPT 72131 | $375.95 |
| MRI cervical spine without contrast | CPT 72141 | $1,510.50 |
| MRI thoracic spine without contrast | CPT 72146 | $793.95 |
| MRI lumbar spine without contrast | CPT 72148 | $2,617.50 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,270.01 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,649.15 |
| MRI lumbar spine with contrast | CPT 72158 | $3,006.00 |
| CT pelvis without contrast | CPT 72192 | $1,029.00 |
| CT pelvis with contrast | CPT 72193 | $1,568.25 |
| Shoulder X-ray | CPT 73030 | $271.50 |
| Humerus X-ray | CPT 73060 | $279.11 |
| Hand X-ray 3 views | CPT 73130 | $144.00 |
| MRI upper extremity joint without contrast | CPT 73221 | $793.95 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,270.01 |
| Knee X-ray 1-2 views | CPT 73560 | $279.11 |
| Ankle X-ray 3 views | CPT 73610 | $137.25 |
| MRI lower extremity joint without contrast | CPT 73721 | $793.95 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,270.01 |
| CT abdomen without contrast | CPT 74150 | $1,035.00 |
| CT abdomen with contrast | CPT 74160 | $2,770.50 |
| CT abdomen with and without contrast | CPT 74170 | $2,544.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,136.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,661.75 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,248.50 |
| MRI abdomen without contrast | CPT 74181 | $1,650.00 |
| MRI abdomen with and without contrast | CPT 74183 | $1,270.01 |
| Abdominal ultrasound complete | CPT 76700 | $783.75 |
| Abdominal ultrasound limited | CPT 76705 | $569.25 |
| Retroperitoneal ultrasound complete | CPT 76770 | $375.95 |
| Transvaginal ultrasound | CPT 76830 | $82.50 |
| Pelvic ultrasound complete | CPT 76856 | $375.95 |
| Scrotal ultrasound | CPT 76870 | $375.95 |
| Screening mammography bilateral | CPT 77067 | $333.44 |
| EKG tracing only | CPT 93005 | $172.50 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,132.50 |
| Transthoracic echocardiogram | CPT 93307 | $793.95 |
| Stress echocardiogram | CPT 93350 | $1,665.97 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $56,573 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $29,639 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $20,789 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $35,254 |
| COPD w MCC | MS-DRG 190 | $28,421 |
| COPD w CC | MS-DRG 191 | $28,421 |
| COPD w/o CC/MCC | MS-DRG 192 | $28,421 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $23,198 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $20,789 |
| AMI discharged alive w MCC | MS-DRG 280 | $35,658 |
| AMI discharged alive w CC | MS-DRG 281 | $27,778 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $20,789 |
| Heart failure & shock w MCC | MS-DRG 291 | $33,466 |
| Heart failure & shock w CC | MS-DRG 292 | $23,763 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $20,789 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $36,411 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $20,789 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $20,789 |
| GI hemorrhage w CC | MS-DRG 378 | $27,778 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $27,778 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $27,243 |
| Fractures of femur w/o MCC | MS-DRG 533 | $31,548 |
| Kidney/UTI w MCC | MS-DRG 689 | $27,478 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $20,441 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $36,919 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $24,738 |
| Basic metabolic panel (BMP) | CPT 80048 | $63.45 |
| Electrolyte panel | CPT 80051 | $110.25 |
| Comprehensive metabolic panel | CPT 80053 | $267.75 |
| Lipid panel | CPT 80061 | $143.25 |
| Renal function panel | CPT 80069 | $150.00 |
| Hepatic function panel | CPT 80076 | $142.50 |
| Urinalysis non-automated | CPT 81002 | $26.10 |
| Urinalysis automated | CPT 81003 | $36.75 |
| Glucose quantitative | CPT 82947 | $29.48 |
| Hemoglobin A1c | CPT 83036 | $84.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $161.25 |
| Complete blood count with automated differential | CPT 85025 | $66.75 |
| Complete blood count without differential | CPT 85027 | $73.50 |
| Urine culture bacterial | CPT 87086 | $73.50 |
| Urine culture identification | CPT 87088 | $60.68 |
| Tissue exam by pathologist level IV | CPT 88305 | $171.68 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,944.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,851.04 |
| Sigmoidoscopy diagnostic | CPT 45330 | $3,215.25 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,796.16 |
| Colonoscopy diagnostic | CPT 45378 | $2,796.16 |
| Colonoscopy with biopsy | CPT 45380 | $1,944.00 |
| Colonoscopy with polyp removal | CPT 45385 | $3,653.76 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $54,899 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $27,778 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $27,778 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $31,548 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $31,548 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $31,274 |
| Major joint replacement w MCC | MS-DRG 469 | $54,899 |
| Major joint replacement w/o MCC | MS-DRG 470 | $29,639 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $29,639 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $29,639 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $29,639 |
| OR procedure for obesity w MCC | MS-DRG 619 | $56,869 |
| OR procedure for obesity w CC | MS-DRG 620 | $41,260 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $29,639 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $54,899 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $54,899 |
