| Psychoses | MS-DRG 885 | $13,534 |
| ED visit level 1 | CPT 99281 | $364.03 |
| ED visit level 2 | CPT 99282 | $603.82 |
| ED visit level 3 | CPT 99283 | $1,095.69 |
| ED visit level 4 | CPT 99284 | $15,903 |
| ED visit level 5 | CPT 99285 | $19,134 |
| Critical care, first hour | CPT 99291 | $22,961 |
| CT head without contrast | CPT 70450 | $207.46 |
| CT head with contrast | CPT 70460 | $232.36 |
| CT head with and without contrast | CPT 70470 | $243.94 |
| CT neck with contrast | CPT 70491 | $396.84 |
| MRI brain without contrast | CPT 70551 | $292.17 |
| MRI brain with contrast | CPT 70552 | $448.71 |
| MRI brain with and without contrast | CPT 70553 | $472.24 |
| Chest X-ray single view | CPT 71045 | $34.65 |
| Chest X-ray 2 views | CPT 71046 | $146.19 |
| Chest X-ray 3 views | CPT 71047 | $111.93 |
| CT chest without contrast | CPT 71250 | $207 |
| CT chest with contrast | CPT 71260 | $419.61 |
| CT chest with and without contrast | CPT 71270 | $232.36 |
| MRI chest without contrast | CPT 71550 | $347 |
| MRI chest with contrast | CPT 71551 | $516.51 |
| MRI chest with and without contrast | CPT 71552 | $448.71 |
| Lumbosacral spine X-ray | CPT 72100 | $235.31 |
| CT cervical spine without contrast | CPT 72125 | $250.1 |
| CT thoracic spine without contrast | CPT 72128 | $207 |
| CT lumbar spine without contrast | CPT 72131 | $207 |
| MRI cervical spine without contrast | CPT 72141 | $402.28 |
| MRI thoracic spine without contrast | CPT 72146 | $347 |
| MRI lumbar spine without contrast | CPT 72148 | $347 |
| MRI lumbar spine with and without contrast | CPT 72149 | $448.71 |
| MRI cervical spine with and without contrast | CPT 72156 | $531.84 |
| MRI lumbar spine with contrast | CPT 72158 | $448.71 |
| CT pelvis without contrast | CPT 72192 | $207 |
| CT pelvis with contrast | CPT 72193 | $232.36 |
| Shoulder X-ray | CPT 73030 | $214.88 |
| Humerus X-ray | CPT 73060 | $567.83 |
| Hand X-ray 3 views | CPT 73130 | $372.41 |
| MRI upper extremity joint without contrast | CPT 73221 | $400.07 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $462.17 |
| Knee X-ray 1-2 views | CPT 73560 | $45.14 |
| Ankle X-ray 3 views | CPT 73610 | $302.59 |
| MRI lower extremity joint without contrast | CPT 73721 | $463.99 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $775.49 |
| CT abdomen without contrast | CPT 74150 | $205.85 |
| CT abdomen with contrast | CPT 74160 | $225.59 |
| CT abdomen with and without contrast | CPT 74170 | $232.46 |
| CT abdomen and pelvis without contrast | CPT 74176 | $349.63 |
| CT abdomen and pelvis with contrast | CPT 74177 | $540 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $567 |
| MRI abdomen without contrast | CPT 74181 | $175.7 |
| MRI abdomen with and without contrast | CPT 74183 | $448.71 |
| Abdominal ultrasound complete | CPT 76700 | $235.31 |
| Abdominal ultrasound limited | CPT 76705 | $304.4 |
| Retroperitoneal ultrasound complete | CPT 76770 | $134.46 |
| Obstetric ultrasound first trimester | CPT 76801 | $500.1 |
| Obstetric ultrasound after first trimester | CPT 76805 | $200.9 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $248.27 |
| Transvaginal ultrasound | CPT 76830 | $274.68 |
| Pelvic ultrasound complete | CPT 76856 | $392.91 |
| Scrotal ultrasound | CPT 76870 | $366.39 |
| Diagnostic mammography unilateral | CPT 77065 | $148.51 |
| Diagnostic mammography bilateral | CPT 77066 | $198.42 |
| Screening mammography bilateral | CPT 77067 | $151.93 |
| EKG tracing only | CPT 93005 | $70.45 |
| Transthoracic echocardiogram complete | CPT 93306 | $836.3 |
| Transthoracic echocardiogram | CPT 93307 | $1,008.25 |
| Stress echocardiogram | CPT 93350 | $2,028.09 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $19,485 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $9,789.2 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,631.42 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,142 |
| COPD w MCC | MS-DRG 190 | $10,733 |
| COPD w CC | MS-DRG 191 | $8,168.17 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,220.59 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,808.67 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,089.78 |
| AMI discharged alive w MCC | MS-DRG 280 | $16,822 |
| AMI discharged alive w CC | MS-DRG 281 | $9,638.69 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,439 |
| Heart failure & shock w CC | MS-DRG 292 | $9,580.8 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,484.21 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,666 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,128.49 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,485.18 |
| GI hemorrhage w CC | MS-DRG 378 | $9,502.39 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,113.96 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,553.85 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,243 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,843.58 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,822 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,548 |
| Initial hospital care, low complexity | CPT 99221 | $42.29 |
| Initial hospital care, moderate complexity | CPT 99222 | $315.26 |
| Initial hospital care, high complexity | CPT 99223 | $161.55 |
| Basic metabolic panel (BMP) | CPT 80048 | $39.04 |
| General health panel | CPT 80050 | $153.84 |
| Electrolyte panel | CPT 80051 | $12.27 |
| Comprehensive metabolic panel | CPT 80053 | $10.56 |
| Renal function panel | CPT 80069 | $15.19 |
| Hepatic function panel | CPT 80076 | $45.57 |
| Urinalysis non-automated | CPT 81002 | $4.49 |
| Urinalysis automated | CPT 81003 | $14.37 |
| Glucose quantitative | CPT 82947 | $5.09 |
| Hemoglobin A1c | CPT 83036 | $8.29 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $28.56 |
| Complete blood count with automated differential | CPT 85025 | $17.6 |
| Complete blood count without differential | CPT 85027 | $22.74 |
| Tissue exam by pathologist level IV | CPT 88305 | $67.02 |
| Fetal non-stress test | CPT 59025 | $260.03 |
| Vaginal delivery only | CPT 59409 | $9,985.52 |
| Office visit, established patient, 5 min | CPT 99211 | $171.24 |
| Office visit, established patient, 10-19 min | CPT 99212 | $37.91 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $88.11 |
| Upper GI endoscopy diagnostic | CPT 43235 | $435.24 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,166.53 |
| Sigmoidoscopy diagnostic | CPT 45330 | $482.69 |
| Sigmoidoscopy with biopsy | CPT 45331 | $660.11 |
| Colonoscopy diagnostic | CPT 45378 | $518.65 |
| Colonoscopy with biopsy | CPT 45380 | $960.19 |
| Colonoscopy with polyp removal | CPT 45385 | $1,127.32 |
| Total shoulder arthroplasty | CPT 23472 | $3,627.92 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,984.77 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,663.2 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,394.91 |
| ACL reconstruction | CPT 29888 | $3,905.35 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $44,537 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $23,227 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,306 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,391 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,234 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,013 |
| Laparoscopic appendectomy | CPT 44970 | $10,024 |
| Major joint replacement w MCC | MS-DRG 469 | $29,390 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,690 |
| Laparoscopic cholecystectomy | CPT 47562 | $8,358.76 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $8,442.38 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,294 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,803 |
| Lap inguinal hernia repair | CPT 49650 | $1,948.2 |
| Vaginal hysterectomy | CPT 58260 | $3,937.66 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $11,425 |
| Lap salpingo-oophorectomy | CPT 58661 | $7,997.39 |
| OR procedure for obesity w MCC | MS-DRG 619 | $27,977 |
| OR procedure for obesity w CC | MS-DRG 620 | $15,506 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,615 |
| Complex cataract surgery | CPT 66982 | $1,504.26 |
| Cataract surgery with lens implant | CPT 66984 | $1,570.35 |
