| Psychoses | MS-DRG 885 | $16,139 |
| ED visit level 1 | CPT 99281 | $588 |
| ED visit level 2 | CPT 99282 | $588 |
| ED visit level 3 | CPT 99283 | $588 |
| ED visit level 4 | CPT 99284 | $588 |
| ED visit level 5 | CPT 99285 | $588 |
| Critical care, first hour | CPT 99291 | $588 |
| CT head without contrast | CPT 70450 | $208.44 |
| CT head with contrast | CPT 70460 | $299.6 |
| CT head with and without contrast | CPT 70470 | $364.13 |
| CT neck with contrast | CPT 70491 | $411.48 |
| Chest X-ray single view | CPT 71045 | $17.41 |
| Chest X-ray 2 views | CPT 71046 | $23.07 |
| Chest X-ray 3 views | CPT 71047 | $27.67 |
| CT chest without contrast | CPT 71250 | $320.07 |
| CT chest with contrast | CPT 71260 | $476.77 |
| CT chest with and without contrast | CPT 71270 | $588.41 |
| Lumbosacral spine X-ray | CPT 72100 | $49.03 |
| CT cervical spine without contrast | CPT 72125 | $320.07 |
| CT thoracic spine without contrast | CPT 72128 | $320.07 |
| CT lumbar spine without contrast | CPT 72131 | $320.07 |
| CT pelvis without contrast | CPT 72192 | $259.65 |
| CT pelvis with contrast | CPT 72193 | $478.81 |
| Shoulder X-ray | CPT 73030 | $41.94 |
| Humerus X-ray | CPT 73060 | $41.94 |
| Hand X-ray 3 views | CPT 73130 | $38.5 |
| Knee X-ray 1-2 views | CPT 73560 | $37.81 |
| Ankle X-ray 3 views | CPT 73610 | $38.5 |
| CT abdomen without contrast | CPT 74150 | $255.57 |
| CT abdomen with contrast | CPT 74160 | $476.77 |
| CT abdomen with and without contrast | CPT 74170 | $548.46 |
| CT abdomen and pelvis without contrast | CPT 74176 | $305.97 |
| CT abdomen and pelvis with contrast | CPT 74177 | $523.64 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $663.51 |
| Abdominal ultrasound complete | CPT 76700 | $145.93 |
| Abdominal ultrasound limited | CPT 76705 | $109.94 |
| Retroperitoneal ultrasound complete | CPT 76770 | $144.61 |
| Obstetric ultrasound first trimester | CPT 76801 | $131.39 |
| Obstetric ultrasound after first trimester | CPT 76805 | $153.11 |
| Transvaginal ultrasound | CPT 76830 | $125.68 |
| Pelvic ultrasound complete | CPT 76856 | $126.3 |
| Scrotal ultrasound | CPT 76870 | $101.94 |
| Diagnostic mammography unilateral | CPT 77065 | — |
| Diagnostic mammography bilateral | CPT 77066 | $113.15 |
| Screening mammography bilateral | CPT 77067 | $106.74 |
| EKG tracing only | CPT 93005 | $23.43 |
| Transthoracic echocardiogram complete | CPT 93306 | $162.02 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $43,147 |
| COPD w MCC | MS-DRG 190 | $18,927 |
| COPD w CC | MS-DRG 191 | $18,927 |
| COPD w/o CC/MCC | MS-DRG 192 | $18,927 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $24,357 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $19,388 |
| AMI discharged alive w MCC | MS-DRG 280 | $34,260 |
| AMI discharged alive w CC | MS-DRG 281 | $29,621 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $25,940 |
| Heart failure & shock w MCC | MS-DRG 291 | $29,197 |
| Heart failure & shock w CC | MS-DRG 292 | $29,197 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $29,197 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $21,618 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $20,288 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $15,550 |
| GI hemorrhage w CC | MS-DRG 378 | $21,866 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $16,768 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $14,904 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,485 |
| Kidney/UTI w MCC | MS-DRG 689 | $17,959 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $15,333 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $41,796 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $41,773 |
| Basic metabolic panel (BMP) | CPT 80048 | $20.08 |
| Electrolyte panel | CPT 80051 | $16.64 |
| Comprehensive metabolic panel | CPT 80053 | $25.1 |
| Lipid panel | CPT 80061 | $31.76 |
| Renal function panel | CPT 80069 | $20.63 |
| Hepatic function panel | CPT 80076 | $19.39 |
| Urinalysis automated | CPT 81003 | $5.36 |
| Glucose quantitative | CPT 82947 | $9.29 |
| Hemoglobin A1c | CPT 83036 | $23.04 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $39.88 |
| Complete blood count with automated differential | CPT 85025 | $18.43 |
| Complete blood count without differential | CPT 85027 | $15.34 |
| Urine culture bacterial | CPT 87086 | $19.19 |
| Urine culture identification | CPT 87088 | $18.15 |
| Tissue exam by pathologist level IV | CPT 88305 | $75.75 |
| Fetal non-stress test | CPT 59025 | $10.04 |
| Office visit, established patient, 5 min | CPT 99211 | $9.17 |
| Office visit, established patient, 10-19 min | CPT 99212 | $24.13 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $36.31 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $56.46 |
| Office visit, established patient, 40-54 min | CPT 99215 | $83.57 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,896 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,837 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,311.13 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,896 |
| Colonoscopy diagnostic | CPT 45378 | $2,837 |
| Colonoscopy with biopsy | CPT 45380 | $2,837 |
| Colonoscopy with polyp removal | CPT 45385 | $2,837 |
| Total shoulder arthroplasty | CPT 23472 | $9,068.17 |
| Hip hemiarthroplasty | CPT 27125 | $2,021.33 |
| Total hip replacement | CPT 27130 | $9,068.17 |
| Total knee replacement | CPT 27447 | $7,010.6 |
| Knee revision arthroplasty single component | CPT 27486 | $1,829.2 |
| Knee revision arthroplasty all components | CPT 27487 | $1,829.2 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,837 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,837 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,837 |
| ACL reconstruction | CPT 29888 | $2,837 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $82,490 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $66,778 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $37,403 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $27,630 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $17,874 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $67,031 |
| Open appendectomy | CPT 44950 | $1,110.05 |
| Laparoscopic appendectomy | CPT 44970 | $1,829.2 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $86,263 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $81,172 |
| Major joint replacement w MCC | MS-DRG 469 | $41,938 |
| Major joint replacement w/o MCC | MS-DRG 470 | $28,473 |
| Laparoscopic cholecystectomy | CPT 47562 | $7,010.6 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $7,010.6 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $50,946 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $49,684 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $35,803 |
| Open umbilical hernia repair | CPT 49560 | $3,715.78 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,715.78 |
| Lap inguinal hernia repair | CPT 49650 | $2,837 |
| Lap incisional hernia repair | CPT 49652 | $816.55 |
| Total abdominal hysterectomy | CPT 58150 | $1,829.2 |
| Vaginal hysterectomy | CPT 58260 | $1,829.2 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $7,613 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $7,010.6 |
| Lap salpingo-oophorectomy | CPT 58661 | $2,837 |
| OR procedure for obesity w MCC | MS-DRG 619 | $52,956 |
| OR procedure for obesity w CC | MS-DRG 620 | $52,956 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $52,725 |
| Complex cataract surgery | CPT 66982 | $2,837 |
| Cataract surgery with lens implant | CPT 66984 | $2,837 |
| Intravitreal injection | CPT 67028 | $3,104 |
| Vitrectomy mechanical | CPT 67042 | $6,032.16 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $20,505 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,023 |
| PCI single major coronary artery | CPT 92920 | $2,021.33 |
| PCI with drug-eluting stent | CPT 92928 | $9,068.17 |
| PCI bypass graft | CPT 92937 | $2,021.33 |
| Left heart catheterization | CPT 93452 | $1,829.2 |
| Coronary angiography with cath | CPT 93455 | $1,829.2 |
| Coronary angiography with bypass cath | CPT 93458 | $7,010.6 |
