| Psychoses | MS-DRG 885 | $9,563.62 |
| Psychiatric diagnostic evaluation | CPT 90791 | $249.48 |
| ED visit level 1 | CPT 99281 | $97.9 |
| ED visit level 2 | CPT 99282 | $552.49 |
| ED visit level 3 | CPT 99283 | $1,257.33 |
| ED visit level 4 | CPT 99284 | $1,442.28 |
| ED visit level 5 | CPT 99285 | $2,375.94 |
| Critical care, first hour | CPT 99291 | $2,866.19 |
| CT head without contrast | CPT 70450 | $1,009 |
| CT head with contrast | CPT 70460 | $1,009 |
| CT head with and without contrast | CPT 70470 | $1,009 |
| CT neck with contrast | CPT 70491 | $1,009 |
| MRI brain without contrast | CPT 70551 | $1,782 |
| MRI brain with contrast | CPT 70552 | $1,782 |
| MRI brain with and without contrast | CPT 70553 | $1,782 |
| Chest X-ray single view | CPT 71045 | $296 |
| Chest X-ray 2 views | CPT 71046 | $296 |
| Chest X-ray 3 views | CPT 71047 | $296 |
| CT chest without contrast | CPT 71250 | $1,009 |
| CT chest with contrast | CPT 71260 | $1,009 |
| CT chest with and without contrast | CPT 71270 | $1,009 |
| MRI chest without contrast | CPT 71550 | $1,766.1 |
| MRI chest with and without contrast | CPT 71552 | $1,782 |
| Lumbosacral spine X-ray | CPT 72100 | $296 |
| CT cervical spine without contrast | CPT 72125 | $1,009 |
| CT thoracic spine without contrast | CPT 72128 | $1,009 |
| CT lumbar spine without contrast | CPT 72131 | $1,009 |
| MRI cervical spine without contrast | CPT 72141 | $1,782 |
| MRI thoracic spine without contrast | CPT 72146 | $1,782 |
| MRI lumbar spine without contrast | CPT 72148 | $1,782 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,782 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,782 |
| MRI lumbar spine with contrast | CPT 72158 | $1,782 |
| CT pelvis without contrast | CPT 72192 | $1,009 |
| CT pelvis with contrast | CPT 72193 | $1,009 |
| Shoulder X-ray | CPT 73030 | $839.83 |
| Humerus X-ray | CPT 73060 | $816.52 |
| Hand X-ray 3 views | CPT 73130 | $697.3 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,678.32 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,782 |
| Knee X-ray 1-2 views | CPT 73560 | $482.18 |
| Ankle X-ray 3 views | CPT 73610 | $777.22 |
| MRI lower extremity joint without contrast | CPT 73721 | $4,160.5 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $5,491.84 |
| CT abdomen without contrast | CPT 74150 | $1,009 |
| CT abdomen with contrast | CPT 74160 | $1,009 |
| CT abdomen with and without contrast | CPT 74170 | $1,009 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,009 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,009 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,009 |
| MRI abdomen without contrast | CPT 74181 | $1,782 |
| MRI abdomen with and without contrast | CPT 74183 | $1,782 |
| Abdominal ultrasound complete | CPT 76700 | $514 |
| Abdominal ultrasound limited | CPT 76705 | $390.95 |
| Retroperitoneal ultrasound complete | CPT 76770 | $514 |
| Obstetric ultrasound first trimester | CPT 76801 | $447.3 |
| Obstetric ultrasound after first trimester | CPT 76805 | $396.2 |
| Transvaginal ultrasound | CPT 76830 | $514 |
| Pelvic ultrasound complete | CPT 76856 | $514 |
| Scrotal ultrasound | CPT 76870 | $514 |
| EKG tracing only | CPT 93005 | $5,549.38 |
| Transthoracic echocardiogram complete | CPT 93306 | $3,088 |
| Transthoracic echocardiogram | CPT 93307 | $1,116.84 |
| Stress echocardiogram | CPT 93350 | $2,017.84 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $13,769 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $7,449.73 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,601 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $10,699 |
| COPD w MCC | MS-DRG 190 | $7,584.2 |
| COPD w CC | MS-DRG 191 | $5,771.85 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,869.58 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $5,601 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,601 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,983 |
| AMI discharged alive w CC | MS-DRG 281 | $6,885.96 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $5,601 |
| Heart failure & shock w MCC | MS-DRG 291 | $8,789.92 |
| Heart failure & shock w CC | MS-DRG 292 | $5,919.51 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,601 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $8,243.55 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,601 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,415.24 |
| GI hemorrhage w CC | MS-DRG 378 | $6,714.65 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,601 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,601 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,015.04 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,542.48 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $13,300 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $7,006.33 |
| Vaginal delivery only | CPT 59409 | $2,935.04 |
| Office visit, new patient, 15-29 min | CPT 99202 | $95.76 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $109.86 |
| Office visit, new patient, 45-59 min | CPT 99204 | $163.35 |
| Office visit, new patient, 60-74 min | CPT 99205 | $180.45 |
| Office visit, established patient, 5 min | CPT 99211 | $112.95 |
| Office visit, established patient, 10-19 min | CPT 99212 | $118.8 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $127.8 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $134.1 |
| Office visit, established patient, 40-54 min | CPT 99215 | $162.45 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | — |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,083 |
| Colonoscopy diagnostic | CPT 45378 | — |
| Colonoscopy with biopsy | CPT 45380 | — |
| Colonoscopy with polyp removal | CPT 45385 | — |
| Total shoulder arthroplasty | CPT 23472 | $4,100 |
| Total hip replacement | CPT 27130 | — |
| Total knee replacement | CPT 27447 | — |
| Knee revision arthroplasty single component | CPT 27486 | $3,208.78 |
| Knee revision arthroplasty all components | CPT 27487 | — |
| Shoulder arthroscopy with decompression | CPT 29826 | — |
| ACL reconstruction | CPT 29888 | — |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $31,471 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $16,413 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $11,522 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $11,582 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $9,351.35 |
| Major joint replacement w MCC | MS-DRG 469 | $20,768 |
| Major joint replacement w/o MCC | MS-DRG 470 | $13,208 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $19,940 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $14,341 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $11,167 |
| Umbilical hernia repair age 5+ | CPT 49585 | $85.65 |
| Vaginal hysterectomy | CPT 58260 | $75.05 |
| OR procedure for obesity w CC | MS-DRG 620 | $10,742 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $10,125 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $8,494.83 |
| PCI single major coronary artery | CPT 92920 | $45.1 |
| PCI with drug-eluting stent | CPT 92928 | $18,923 |
| PCI bypass graft | CPT 92937 | $19,414 |
| Left heart catheterization | CPT 93452 | $8,825.4 |
| Coronary angiography with cath | CPT 93455 | $11,133 |
| Coronary angiography with bypass cath | CPT 93458 | $11,133 |
