| Psychoses | MS-DRG 885 | $12,064 |
| ED visit level 1 | CPT 99281 | $65.72 |
| ED visit level 2 | CPT 99282 | $118.20 |
| ED visit level 3 | CPT 99283 | $206.66 |
| ED visit level 4 | CPT 99284 | $317.82 |
| ED visit level 5 | CPT 99285 | $1,772.44 |
| Critical care, first hour | CPT 99291 | $195.02 |
| CT head without contrast | CPT 70450 | $474.00 |
| CT head with contrast | CPT 70460 | $474.00 |
| CT head with and without contrast | CPT 70470 | $474.00 |
| CT neck with contrast | CPT 70491 | $474.00 |
| MRI brain without contrast | CPT 70551 | $663.00 |
| MRI brain with contrast | CPT 70552 | $663.00 |
| MRI brain with and without contrast | CPT 70553 | $663.00 |
| Chest X-ray single view | CPT 71045 | $124.99 |
| Chest X-ray 2 views | CPT 71046 | $146.16 |
| CT chest without contrast | CPT 71250 | $474.00 |
| CT chest with contrast | CPT 71260 | $474.00 |
| CT chest with and without contrast | CPT 71270 | $474.00 |
| MRI chest without contrast | CPT 71550 | $663.00 |
| Lumbosacral spine X-ray | CPT 72100 | $169.07 |
| CT cervical spine without contrast | CPT 72125 | $474.00 |
| CT thoracic spine without contrast | CPT 72128 | $474.00 |
| CT lumbar spine without contrast | CPT 72131 | $474.00 |
| MRI cervical spine without contrast | CPT 72141 | $663.00 |
| MRI thoracic spine without contrast | CPT 72146 | $663.00 |
| MRI lumbar spine without contrast | CPT 72148 | $663.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $663.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $663.00 |
| MRI lumbar spine with contrast | CPT 72158 | $663.00 |
| CT pelvis without contrast | CPT 72192 | $474.00 |
| CT pelvis with contrast | CPT 72193 | $474.00 |
| Shoulder X-ray | CPT 73030 | $224.28 |
| Humerus X-ray | CPT 73060 | $224.28 |
| Hand X-ray 3 views | CPT 73130 | $224.73 |
| MRI upper extremity joint without contrast | CPT 73221 | $663.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $663.00 |
| Knee X-ray 1-2 views | CPT 73560 | $208.71 |
| Ankle X-ray 3 views | CPT 73610 | $237.63 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,750.98 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $663.00 |
| CT abdomen without contrast | CPT 74150 | $474.00 |
| CT abdomen with contrast | CPT 74160 | $474.00 |
| CT abdomen with and without contrast | CPT 74170 | $474.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $474.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $474.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $474.00 |
| MRI abdomen without contrast | CPT 74181 | $663.00 |
| MRI abdomen with and without contrast | CPT 74183 | $663.00 |
| Abdominal ultrasound complete | CPT 76700 | $489.23 |
| Abdominal ultrasound limited | CPT 76705 | $297.83 |
| Retroperitoneal ultrasound complete | CPT 76770 | $260.13 |
| Obstetric ultrasound first trimester | CPT 76801 | $424.85 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $626.69 |
| Transvaginal ultrasound | CPT 76830 | $465.16 |
| Pelvic ultrasound complete | CPT 76856 | $408.32 |
| Scrotal ultrasound | CPT 76870 | $465.16 |
| Diagnostic mammography unilateral | CPT 77065 | $36.71 |
| Diagnostic mammography bilateral | CPT 77066 | $104.00 |
| Screening mammography bilateral | CPT 77067 | $104.00 |
| EKG complete | CPT 93000 | $101.46 |
| EKG tracing only | CPT 93005 | — |
| EKG interpretation only | CPT 93010 | $11.44 |
| Transthoracic echocardiogram complete | CPT 93306 | $409.24 |
| Transthoracic echocardiogram | CPT 93307 | $41.88 |
| Stress echocardiogram | CPT 93350 | $409.24 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,497 |
| COPD w MCC | MS-DRG 190 | $9,566.92 |
| COPD w CC | MS-DRG 191 | $7,280.77 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,544.79 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,960.35 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,428.19 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,854 |
| AMI discharged alive w CC | MS-DRG 281 | $7,938.03 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,245.23 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,088 |
| Heart failure & shock w CC | MS-DRG 292 | $7,332.59 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,888.39 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,399 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,354.05 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,889.26 |
| GI hemorrhage w CC | MS-DRG 378 | $8,470.05 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,444.60 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,733.20 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,021 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,991.44 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,777 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,837.98 |
| Initial hospital care, low complexity | CPT 99221 | $72.79 |
| Initial hospital care, moderate complexity | CPT 99222 | $114.33 |
| Initial hospital care, high complexity | CPT 99223 | $152.94 |
| Hospital discharge, <30 min | CPT 99238 | $72.54 |
| Hospital discharge, >30 min | CPT 99239 | $103.34 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.46 |
| Electrolyte panel | CPT 80051 | $7.01 |
| Comprehensive metabolic panel | CPT 80053 | $10.56 |
| Lipid panel | CPT 80061 | $13.39 |
| Renal function panel | CPT 80069 | $8.68 |
| Hepatic function panel | CPT 80076 | $8.17 |
| Urinalysis non-automated | CPT 81002 | $36.00 |
| Urinalysis automated | CPT 81003 | $2.25 |
| Glucose quantitative | CPT 82947 | $3.93 |
| Hemoglobin A1c | CPT 83036 | $9.71 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $16.80 |
| Complete blood count with automated differential | CPT 85025 | $7.77 |
| Complete blood count without differential | CPT 85027 | $6.47 |
| Urine culture bacterial | CPT 87086 | $8.07 |
| Tissue exam by pathologist level IV | CPT 88305 | $39.88 |
| Fetal non-stress test | CPT 59025 | $150.15 |
| Office visit, new patient, 15-29 min | CPT 99202 | $40.23 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $69.96 |
| Office visit, new patient, 45-59 min | CPT 99204 | $114.34 |
| Office visit, new patient, 60-74 min | CPT 99205 | $143.29 |
| Office visit, established patient, 5 min | CPT 99211 | $16.86 |
| Office visit, established patient, 10-19 min | CPT 99212 | $30.41 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $53.77 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $79.16 |
| Office visit, established patient, 40-54 min | CPT 99215 | $98.39 |
| Upper GI endoscopy diagnostic | CPT 43235 | $106.59 |
| Upper GI endoscopy with biopsy | CPT 43239 | $119.33 |
| Sigmoidoscopy diagnostic | CPT 45330 | $51.20 |
| Sigmoidoscopy with biopsy | CPT 45331 | $63.94 |
| Colonoscopy diagnostic | CPT 45378 | $159.33 |
| Colonoscopy with biopsy | CPT 45380 | $172.05 |
| Colonoscopy with polyp removal | CPT 45385 | $216.70 |
| Total shoulder arthroplasty | CPT 23472 | $1,245.94 |
| Total hip replacement | CPT 27130 | $1,112.92 |
| Total knee replacement | CPT 27447 | $1,110.51 |
| Knee revision arthroplasty single component | CPT 27486 | $1,219.57 |
| Knee revision arthroplasty all components | CPT 27487 | $1,510.09 |
| Shoulder arthroscopy with decompression | CPT 29826 | $143.32 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $931.56 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $487.50 |
| ACL reconstruction | CPT 29888 | $849.01 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $39,699 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $20,704 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,535 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,610 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,796 |
| Open appendectomy | CPT 44950 | $581.83 |
| Laparoscopic appendectomy | CPT 44970 | $552.95 |
| Major joint replacement w/o MCC | MS-DRG 470 | $16,659 |
| Laparoscopic cholecystectomy | CPT 47562 | $604.97 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $655.67 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $25,153 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $18,090 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,087 |
| Lap inguinal hernia repair | CPT 49650 | $403.51 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,716 |
| PCI single major coronary artery | CPT 92920 | $4,433.81 |
| PCI with drug-eluting stent | CPT 92928 | $8,464.28 |
| PCI bypass graft | CPT 92937 | $8,464.28 |
| Coronary angiography with cath | CPT 93455 | $2,400.64 |
| Coronary angiography with bypass cath | CPT 93458 | $2,400.64 |
