| Psychoses | MS-DRG 885 | $9,442.70 |
| Psychiatric diagnostic evaluation | CPT 90791 | $550.00 |
| ED visit level 1 | CPT 99281 | $200.00 |
| ED visit level 2 | CPT 99282 | $715.00 |
| ED visit level 3 | CPT 99283 | $770.00 |
| ED visit level 4 | CPT 99284 | $1,100.00 |
| ED visit level 5 | CPT 99285 | $1,540.00 |
| Critical care, first hour | CPT 99291 | $237.72 |
| CT head without contrast | CPT 70450 | $336.00 |
| CT head with contrast | CPT 70460 | $2,630.50 |
| CT head with and without contrast | CPT 70470 | $4,083.00 |
| CT neck with contrast | CPT 70491 | $336.00 |
| MRI brain without contrast | CPT 70551 | $2,591.00 |
| MRI brain with contrast | CPT 70552 | $2,310.00 |
| MRI brain with and without contrast | CPT 70553 | $3,327.50 |
| Chest X-ray single view | CPT 71045 | $103.00 |
| Chest X-ray 2 views | CPT 71046 | $300.00 |
| Chest X-ray 3 views | CPT 71047 | $434.00 |
| CT chest without contrast | CPT 71250 | $336.00 |
| CT chest with contrast | CPT 71260 | $336.00 |
| CT chest with and without contrast | CPT 71270 | $336.00 |
| MRI chest without contrast | CPT 71550 | $616.00 |
| MRI chest with contrast | CPT 71551 | $616.00 |
| MRI chest with and without contrast | CPT 71552 | $616.00 |
| Lumbosacral spine X-ray | CPT 72100 | $39.52 |
| CT cervical spine without contrast | CPT 72125 | $336.00 |
| CT thoracic spine without contrast | CPT 72128 | $2,847.50 |
| CT lumbar spine without contrast | CPT 72131 | $336.00 |
| MRI cervical spine without contrast | CPT 72141 | $616.00 |
| MRI thoracic spine without contrast | CPT 72146 | $2,591.00 |
| MRI lumbar spine without contrast | CPT 72148 | $616.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $616.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $616.00 |
| MRI lumbar spine with contrast | CPT 72158 | $3,327.50 |
| CT pelvis without contrast | CPT 72192 | $3,279.50 |
| CT pelvis with contrast | CPT 72193 | $3,735.00 |
| Shoulder X-ray | CPT 73030 | $34.80 |
| Humerus X-ray | CPT 73060 | $33.77 |
| Hand X-ray 3 views | CPT 73130 | $259.74 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,787.50 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,574.00 |
| Knee X-ray 1-2 views | CPT 73560 | $36.90 |
| Ankle X-ray 3 views | CPT 73610 | $38.49 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,574.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,574.00 |
| CT abdomen without contrast | CPT 74150 | $336.00 |
| CT abdomen with contrast | CPT 74160 | $2,944.50 |
| CT abdomen with and without contrast | CPT 74170 | $4,465.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $5,113.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $5,628.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $336.00 |
| MRI abdomen without contrast | CPT 74181 | $616.00 |
| MRI abdomen with and without contrast | CPT 74183 | $616.00 |
| Abdominal ultrasound complete | CPT 76700 | $121.28 |
| Abdominal ultrasound limited | CPT 76705 | $658.50 |
| Retroperitoneal ultrasound complete | CPT 76770 | $112.90 |
| Obstetric ultrasound first trimester | CPT 76801 | $959.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $959.00 |
| Transvaginal ultrasound | CPT 76830 | $1,157.00 |
| Pelvic ultrasound complete | CPT 76856 | $550.00 |
| Scrotal ultrasound | CPT 76870 | $783.00 |
| Diagnostic mammography unilateral | CPT 77065 | $76.67 |
| Diagnostic mammography bilateral | CPT 77066 | $98.38 |
| Screening mammography bilateral | CPT 77067 | $412.50 |
| EKG tracing only | CPT 93005 | $11.63 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,075.00 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $13,732 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $6,898.86 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $4,673.44 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $10,671 |
| COPD w MCC | MS-DRG 190 | $7,563.96 |
| COPD w CC | MS-DRG 191 | $5,756.45 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,383.91 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $5,503.11 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,291.73 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,954 |
| AMI discharged alive w CC | MS-DRG 281 | $6,276.10 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $4,937.71 |
| Heart failure & shock w MCC | MS-DRG 291 | $8,766.46 |
| Heart failure & shock w CC | MS-DRG 292 | $5,797.42 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $3,864.94 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $8,221.55 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,023.74 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $3,865.63 |
| GI hemorrhage w CC | MS-DRG 378 | $6,696.73 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,304.70 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,323.52 |
| Fractures of femur w/o MCC | MS-DRG 533 | $10,705 |
| Kidney/UTI w MCC | MS-DRG 689 | $7,923.14 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,527.69 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $13,264 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $6,987.63 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.46 |
| Electrolyte panel | CPT 80051 | $162.60 |
| Comprehensive metabolic panel | CPT 80053 | $10.56 |
| Lipid panel | CPT 80061 | $73.03 |
| Renal function panel | CPT 80069 | $183.30 |
| Hepatic function panel | CPT 80076 | $228.00 |
| Urinalysis non-automated | CPT 81002 | $3.48 |
| Urinalysis automated | CPT 81003 | $2.25 |
| Glucose quantitative | CPT 82947 | $124.00 |
| Hemoglobin A1c | CPT 83036 | $9.71 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $115.00 |
| 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 | $80.00 |
| Vaginal delivery only | CPT 59409 | $5,895.00 |
| Cesarean section w CC/MCC | MS-DRG 765 | $8,037.17 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $5,716.16 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $5,670.41 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $4,407.13 |
| Upper GI endoscopy diagnostic | CPT 43235 | $349.65 |
| Upper GI endoscopy with biopsy | CPT 43239 | $468.30 |
| Colonoscopy diagnostic | CPT 45378 | $468.30 |
| Colonoscopy with biopsy | CPT 45380 | $468.30 |
| Colonoscopy with polyp removal | CPT 45385 | $468.30 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $20,454 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $13,039 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $31,387 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $16,369 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $11,492 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $11,551 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $9,326.40 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $23,265 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $45,289 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $24,978 |
| Major joint replacement w MCC | MS-DRG 469 | $934.82 |
| Major joint replacement w/o MCC | MS-DRG 470 | $934.82 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $19,887 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $14,302 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $11,137 |
| OR procedure for obesity w MCC | MS-DRG 619 | $19,717 |
| OR procedure for obesity w CC | MS-DRG 620 | $10,928 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $10,300 |
| Cataract surgery with lens implant | CPT 66984 | $947.57 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $8,472.15 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $13,992 |
| PCI single major coronary artery | CPT 92920 | $740.54 |
| PCI with drug-eluting stent | CPT 92928 | $823.84 |
| PCI bypass graft | CPT 92937 | $822.94 |
| Left heart catheterization | CPT 93452 | $4,050.00 |
| Coronary angiography with cath | CPT 93455 | $4,050.00 |
| Coronary angiography with bypass cath | CPT 93458 | $4,050.00 |
