| Psychoses | MS-DRG 885 | $14,421 |
| Psychiatric eval with medical services | CPT 90792 | $99.78 |
| ED visit level 1 | CPT 99281 | $174.84 |
| ED visit level 2 | CPT 99282 | $301.99 |
| ED visit level 3 | CPT 99283 | $576.6 |
| ED visit level 4 | CPT 99284 | $914.35 |
| ED visit level 5 | CPT 99285 | $1,163.36 |
| Critical care, first hour | CPT 99291 | $1,445.92 |
| CT head without contrast | CPT 70450 | $1,036.33 |
| CT head with contrast | CPT 70460 | $1,461.19 |
| CT head with and without contrast | CPT 70470 | $1,709.7 |
| CT neck with contrast | CPT 70491 | $1,397.51 |
| MRI brain without contrast | CPT 70551 | $1,067.9 |
| MRI brain with contrast | CPT 70552 | $1,482.52 |
| MRI brain with and without contrast | CPT 70553 | $2,179.79 |
| Chest X-ray single view | CPT 71045 | $158.5 |
| Chest X-ray 2 views | CPT 71046 | $196.03 |
| Chest X-ray 3 views | CPT 71047 | $236.65 |
| CT chest without contrast | CPT 71250 | $590.98 |
| CT chest with contrast | CPT 71260 | $1,312 |
| CT chest with and without contrast | CPT 71270 | $1,088.44 |
| MRI chest without contrast | CPT 71550 | $1,151 |
| MRI chest with and without contrast | CPT 71552 | $2,073.13 |
| Lumbosacral spine X-ray | CPT 72100 | $195.59 |
| CT cervical spine without contrast | CPT 72125 | $1,255.45 |
| CT thoracic spine without contrast | CPT 72128 | $1,040.78 |
| CT lumbar spine without contrast | CPT 72131 | $593.21 |
| MRI cervical spine without contrast | CPT 72141 | $1,205.66 |
| MRI thoracic spine without contrast | CPT 72146 | $1,276.76 |
| MRI lumbar spine without contrast | CPT 72148 | $1,296.76 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,402.43 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,231.33 |
| MRI lumbar spine with contrast | CPT 72158 | $2,402.43 |
| CT pelvis without contrast | CPT 72192 | $626.61 |
| CT pelvis with contrast | CPT 72193 | $1,333.38 |
| Shoulder X-ray | CPT 73030 | $205.74 |
| Humerus X-ray | CPT 73060 | $148.35 |
| Hand X-ray 3 views | CPT 73130 | $181.02 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,594.51 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,965.04 |
| Knee X-ray 1-2 views | CPT 73560 | $155.85 |
| Ankle X-ray 3 views | CPT 73610 | $162.47 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,588.29 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,953.49 |
| CT abdomen without contrast | CPT 74150 | $1,266.58 |
| CT abdomen with contrast | CPT 74160 | $1,951.97 |
| CT abdomen with and without contrast | CPT 74170 | $2,215.17 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,687.88 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,637.37 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,979.84 |
| MRI abdomen without contrast | CPT 74181 | $1,230.99 |
| MRI abdomen with and without contrast | CPT 74183 | $2,279.33 |
| Abdominal ultrasound complete | CPT 76700 | $452.7 |
| Abdominal ultrasound limited | CPT 76705 | $337.97 |
| Retroperitoneal ultrasound complete | CPT 76770 | $421.69 |
| Obstetric ultrasound first trimester | CPT 76801 | $275.07 |
| Obstetric ultrasound after first trimester | CPT 76805 | $576.73 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $442.95 |
| Transvaginal ultrasound | CPT 76830 | $399.99 |
| Pelvic ultrasound complete | CPT 76856 | $488.14 |
| Scrotal ultrasound | CPT 76870 | $382.71 |
| Diagnostic mammography unilateral | CPT 77065 | $407.19 |
| Diagnostic mammography bilateral | CPT 77066 | $682.95 |
| Screening mammography bilateral | CPT 77067 | $164.68 |
| EKG tracing only | CPT 93005 | $128.92 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,000.44 |
| Stress echocardiogram | CPT 93350 | $1,248.12 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $20,351 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,403 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,041.72 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $16,538 |
| COPD w MCC | MS-DRG 190 | $11,489 |
| COPD w CC | MS-DRG 191 | $8,789.1 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,621.24 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,389.08 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,402.45 |
| AMI discharged alive w MCC | MS-DRG 280 | $16,792 |
| AMI discharged alive w CC | MS-DRG 281 | $9,430.56 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,455.3 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,349 |
| Heart failure & shock w CC | MS-DRG 292 | $8,810.58 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,641.59 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,337 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,601.3 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,752.64 |
| GI hemorrhage w CC | MS-DRG 378 | $10,086 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,520.41 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,982.93 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,601 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,973 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,211.07 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $20,073 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,548 |
| Basic metabolic panel (BMP) | CPT 80048 | $91.52 |
| General health panel | CPT 80050 | $16.62 |
| Electrolyte panel | CPT 80051 | $51.22 |
| Comprehensive metabolic panel | CPT 80053 | $103.31 |
| Lipid panel | CPT 80061 | $79.91 |
| Renal function panel | CPT 80069 | $80.8 |
| Hepatic function panel | CPT 80076 | $76.82 |
| Urinalysis non-automated | CPT 81002 | $18.04 |
| Urinalysis automated | CPT 81003 | $17.6 |
| Glucose quantitative | CPT 82947 | $11.04 |
| Hemoglobin A1c | CPT 83036 | $51.04 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $62.92 |
| Complete blood count with automated differential | CPT 85025 | $57.84 |
| Complete blood count without differential | CPT 85027 | $48.57 |
| Urine culture bacterial | CPT 87086 | $19.87 |
| Urine culture identification | CPT 87088 | $36.21 |
| Tissue exam by pathologist level IV | CPT 88305 | $155.41 |
| Fetal non-stress test | CPT 59025 | $172.19 |
| Vaginal delivery only | CPT 59409 | $5,811.91 |
| Cesarean section w CC/MCC | MS-DRG 765 | $6,955 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $6,955 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $6,955 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $6,955 |
| Sigmoidoscopy diagnostic | CPT 45330 | $820.31 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $9,417 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $9,417 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $46,978 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $24,182 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,891 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,966 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,480 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $36,109 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $9,417 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $9,417 |
| Major joint replacement w MCC | MS-DRG 469 | $33,441 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,290 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $30,088 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $21,227 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $16,311 |
| OR procedure for obesity w MCC | MS-DRG 619 | $27,894 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,338 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,955 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,263 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $19,991 |
