| Psychoses | MS-DRG 885 | $3,553.21 |
| ED visit level 1 | CPT 99281 | $158.88 |
| ED visit level 2 | CPT 99282 | $332.64 |
| ED visit level 3 | CPT 99283 | $519.36 |
| ED visit level 4 | CPT 99284 | $826.56 |
| ED visit level 5 | CPT 99285 | $1,179.36 |
| Critical care, first hour | CPT 99291 | $1,864.8 |
| CT head without contrast | CPT 70450 | $834.9 |
| CT head with contrast | CPT 70460 | $1,231.8 |
| CT head with and without contrast | CPT 70470 | $1,464.9 |
| CT neck with contrast | CPT 70491 | $1,458.6 |
| MRI brain without contrast | CPT 70551 | $1,310.4 |
| MRI brain with contrast | CPT 70552 | $1,360.8 |
| MRI brain with and without contrast | CPT 70553 | $1,767.3 |
| Chest X-ray single view | CPT 71045 | $231.84 |
| Chest X-ray 2 views | CPT 71046 | $272.16 |
| Chest X-ray 3 views | CPT 71047 | $489.12 |
| CT chest without contrast | CPT 71250 | $1,058.4 |
| CT chest with contrast | CPT 71260 | $1,332.6 |
| CT chest with and without contrast | CPT 71270 | $1,464.9 |
| MRI chest without contrast | CPT 71550 | $1,200 |
| MRI chest with contrast | CPT 71551 | $1,414.5 |
| MRI chest with and without contrast | CPT 71552 | $1,455.3 |
| Lumbosacral spine X-ray | CPT 72100 | $483.84 |
| CT cervical spine without contrast | CPT 72125 | $1,345.2 |
| CT thoracic spine without contrast | CPT 72128 | $1,124.7 |
| CT lumbar spine without contrast | CPT 72131 | $756 |
| MRI cervical spine without contrast | CPT 72141 | $1,565.7 |
| MRI thoracic spine without contrast | CPT 72146 | $1,310.4 |
| MRI lumbar spine without contrast | CPT 72148 | $1,565.7 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,679.1 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,094.9 |
| MRI lumbar spine with contrast | CPT 72158 | $2,120.1 |
| CT pelvis without contrast | CPT 72192 | $1,074.3 |
| CT pelvis with contrast | CPT 72193 | $1,215.9 |
| Shoulder X-ray | CPT 73030 | $453.6 |
| Humerus X-ray | CPT 73060 | $428.64 |
| Hand X-ray 3 views | CPT 73130 | $352.8 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,603.5 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,455.3 |
| Knee X-ray 1-2 views | CPT 73560 | $352.8 |
| Ankle X-ray 3 views | CPT 73610 | $322.56 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,200 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,320 |
| CT abdomen without contrast | CPT 74150 | $1,137.3 |
| CT abdomen with contrast | CPT 74160 | $1,464.9 |
| CT abdomen with and without contrast | CPT 74170 | $1,603.5 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,675.8 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,709 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,976.9 |
| MRI abdomen without contrast | CPT 74181 | $1,200 |
| MRI abdomen with and without contrast | CPT 74183 | $1,364.1 |
| Abdominal ultrasound complete | CPT 76700 | $1,128.96 |
| Abdominal ultrasound limited | CPT 76705 | $705.6 |
| Retroperitoneal ultrasound complete | CPT 76770 | $741.12 |
| Obstetric ultrasound first trimester | CPT 76801 | $806.4 |
| Obstetric ultrasound after first trimester | CPT 76805 | $806.4 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $806.4 |
| Transvaginal ultrasound | CPT 76830 | $912.48 |
| Pelvic ultrasound complete | CPT 76856 | $826.56 |
| Scrotal ultrasound | CPT 76870 | $771.36 |
| Diagnostic mammography unilateral | CPT 77065 | $292.32 |
| Diagnostic mammography bilateral | CPT 77066 | $352.8 |
| Screening mammography bilateral | CPT 77067 | $249.6 |
| EKG tracing only | CPT 93005 | $229.44 |
| EKG interpretation only | CPT 93010 | $50.4 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,940.64 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $3,553.21 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $3,553.21 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $3,553.21 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $3,553.21 |
| COPD w MCC | MS-DRG 190 | $3,553.21 |
| COPD w CC | MS-DRG 191 | $3,553.21 |
| COPD w/o CC/MCC | MS-DRG 192 | $3,553.21 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $3,553.21 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $3,553.21 |
| AMI discharged alive w MCC | MS-DRG 280 | $3,553.21 |
| AMI discharged alive w CC | MS-DRG 281 | $3,553.21 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $3,553.21 |
| Heart failure & shock w MCC | MS-DRG 291 | $3,553.21 |
| Heart failure & shock w CC | MS-DRG 292 | $3,553.21 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $3,553.21 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $3,553.21 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $3,553.21 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $3,553.21 |
| GI hemorrhage w CC | MS-DRG 378 | $3,553.21 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $3,553.21 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $3,553.21 |
| Fractures of femur w/o MCC | MS-DRG 533 | $3,553.21 |
| Kidney/UTI w MCC | MS-DRG 689 | $3,553.21 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $3,553.21 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $3,553.21 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $3,553.21 |
| Initial hospital care, low complexity | CPT 99221 | $47.04 |
| Initial hospital care, moderate complexity | CPT 99222 | $189 |
| Initial hospital care, high complexity | CPT 99223 | $187.5 |
| Hospital discharge, <30 min | CPT 99238 | $86.7 |
| Hospital discharge, >30 min | CPT 99239 | $123 |
| Basic metabolic panel (BMP) | CPT 80048 | $146.4 |
| General health panel | CPT 80050 | $204 |
| Electrolyte panel | CPT 80051 | $90.72 |
| Comprehensive metabolic panel | CPT 80053 | $241.92 |
| Lipid panel | CPT 80061 | $143.52 |
| Renal function panel | CPT 80069 | $181.44 |
| Hepatic function panel | CPT 80076 | $216.96 |
| Urinalysis non-automated | CPT 81002 | $46.56 |
| Urinalysis automated | CPT 81003 | $46.56 |
| Glucose quantitative | CPT 82947 | $93.12 |
| Hemoglobin A1c | CPT 83036 | $148.8 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $126.24 |
| Complete blood count with automated differential | CPT 85025 | $80.64 |
| Complete blood count without differential | CPT 85027 | $10.56 |
| Urine culture bacterial | CPT 87086 | $126.24 |
| Urine culture identification | CPT 87088 | $90.72 |
| Tissue exam by pathologist level IV | CPT 88305 | $244.8 |
| Fetal non-stress test | CPT 59025 | $428.64 |
| Cesarean section w CC/MCC | MS-DRG 765 | $3,553.21 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $3,553.21 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $3,553.21 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $3,553.21 |
| Upper GI endoscopy diagnostic | CPT 43235 | $557.7 |
| Upper GI endoscopy with biopsy | CPT 43239 | $822.3 |
| Sigmoidoscopy diagnostic | CPT 45330 | $327.6 |
| Sigmoidoscopy with biopsy | CPT 45331 | $400.2 |
| Colonoscopy diagnostic | CPT 45378 | $913.5 |
| Colonoscopy with biopsy | CPT 45380 | $1,089.9 |
| Colonoscopy with polyp removal | CPT 45385 | $1,228.5 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $3,553.21 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $3,553.21 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $3,553.21 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $3,553.21 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $3,553.21 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $3,553.21 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $3,553.21 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $3,553.21 |
| Laparoscopic appendectomy | CPT 44970 | $1,464.9 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $3,553.21 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $3,553.21 |
| Major joint replacement w MCC | MS-DRG 469 | $3,553.21 |
| Major joint replacement w/o MCC | MS-DRG 470 | $3,553.21 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,745.1 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $10,850 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $3,553.21 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $3,553.21 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $3,553.21 |
| Lap inguinal hernia repair | CPT 49650 | $1,348.2 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $10,850 |
| Lap salpingo-oophorectomy | CPT 58661 | $10,850 |
| OR procedure for obesity w MCC | MS-DRG 619 | $3,553.21 |
| OR procedure for obesity w CC | MS-DRG 620 | $3,553.21 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $3,553.21 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,337 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $3,553.21 |
