| Psychoses | MS-DRG 885 | $11,671 |
| Psychiatric diagnostic evaluation | CPT 90791 | $175.13 |
| ED visit level 1 | CPT 99281 | $83.2 |
| ED visit level 2 | CPT 99282 | $151.49 |
| ED visit level 3 | CPT 99283 | $269.34 |
| ED visit level 4 | CPT 99284 | $411.71 |
| ED visit level 5 | CPT 99285 | $587.61 |
| Critical care, first hour | CPT 99291 | $815.04 |
| CT head without contrast | CPT 70450 | $103.15 |
| CT head with contrast | CPT 70460 | $173.07 |
| CT head with and without contrast | CPT 70470 | $173.07 |
| CT neck with contrast | CPT 70491 | $173.07 |
| MRI brain without contrast | CPT 70551 | $235.42 |
| MRI brain with contrast | CPT 70552 | $344.22 |
| MRI brain with and without contrast | CPT 70553 | $344.22 |
| Chest X-ray single view | CPT 71045 | $85.87 |
| Chest X-ray 2 views | CPT 71046 | $85.87 |
| Chest X-ray 3 views | CPT 71047 | $85.87 |
| CT chest without contrast | CPT 71250 | $103.15 |
| CT chest with contrast | CPT 71260 | $173.07 |
| CT chest with and without contrast | CPT 71270 | $173.07 |
| MRI chest without contrast | CPT 71550 | $235.42 |
| MRI chest with contrast | CPT 71551 | $773.49 |
| MRI chest with and without contrast | CPT 71552 | $344.22 |
| Lumbosacral spine X-ray | CPT 72100 | $103.15 |
| CT cervical spine without contrast | CPT 72125 | $103.15 |
| CT thoracic spine without contrast | CPT 72128 | $103.15 |
| CT lumbar spine without contrast | CPT 72131 | $103.15 |
| MRI cervical spine without contrast | CPT 72141 | $235.42 |
| MRI thoracic spine without contrast | CPT 72146 | $235.42 |
| MRI lumbar spine without contrast | CPT 72148 | $235.42 |
| MRI lumbar spine with and without contrast | CPT 72149 | $344.22 |
| MRI cervical spine with and without contrast | CPT 72156 | $344.22 |
| MRI lumbar spine with contrast | CPT 72158 | $344.22 |
| CT pelvis without contrast | CPT 72192 | $103.15 |
| CT pelvis with contrast | CPT 72193 | $173.07 |
| Shoulder X-ray | CPT 73030 | $85.87 |
| Humerus X-ray | CPT 73060 | $85.87 |
| Hand X-ray 3 views | CPT 73130 | $85.87 |
| MRI upper extremity joint without contrast | CPT 73221 | $235.42 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $344.22 |
| Knee X-ray 1-2 views | CPT 73560 | $85.87 |
| Ankle X-ray 3 views | CPT 73610 | $85.87 |
| MRI lower extremity joint without contrast | CPT 73721 | $235.42 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $344.22 |
| CT abdomen without contrast | CPT 74150 | $103.15 |
| CT abdomen with contrast | CPT 74160 | $173.07 |
| CT abdomen with and without contrast | CPT 74170 | $173.07 |
| CT abdomen and pelvis without contrast | CPT 74176 | $235.42 |
| CT abdomen and pelvis with contrast | CPT 74177 | $344.22 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $344.22 |
| MRI abdomen without contrast | CPT 74181 | $235.42 |
| MRI abdomen with and without contrast | CPT 74183 | $344.22 |
| Abdominal ultrasound complete | CPT 76700 | $103.15 |
| Abdominal ultrasound limited | CPT 76705 | $103.15 |
| Retroperitoneal ultrasound complete | CPT 76770 | $103.15 |
| Obstetric ultrasound first trimester | CPT 76801 | $103.15 |
| Obstetric ultrasound after first trimester | CPT 76805 | $103.15 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $235.42 |
| Transvaginal ultrasound | CPT 76830 | $103.15 |
| Pelvic ultrasound complete | CPT 76856 | $103.15 |
| Scrotal ultrasound | CPT 76870 | $103.15 |
| Diagnostic mammography unilateral | CPT 77065 | $79.18 |
| Diagnostic mammography bilateral | CPT 77066 | $101.51 |
| Screening mammography bilateral | CPT 77067 | $83.79 |
| Transthoracic echocardiogram complete | CPT 93306 | $539.15 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,342 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,731.75 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,253.16 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,933 |
| COPD w MCC | MS-DRG 190 | $9,472.51 |
| COPD w CC | MS-DRG 191 | $7,459.37 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,930.69 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,177.21 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,828.02 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,248 |
| AMI discharged alive w CC | MS-DRG 281 | $8,038.14 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,547.48 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,812 |
| Heart failure & shock w CC | MS-DRG 292 | $7,505 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,352.68 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,205 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,643.31 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,353.44 |
| GI hemorrhage w CC | MS-DRG 378 | $8,506.63 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,842.47 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,977.19 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,971 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,872.55 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,204.59 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,822 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,830.62 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.46 |
| General health panel | CPT 80050 | $170.33 |
| 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 | $3.48 |
| Urinalysis automated | CPT 81003 | $2.25 |
| Glucose quantitative | CPT 82947 | $3.93 |
| Hemoglobin A1c | CPT 83036 | $9.71 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $16.8 |
| Complete blood count with automated differential | CPT 85025 | $7.77 |
| Complete blood count without differential | CPT 85027 | $6.47 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $53.74 |
| Fetal non-stress test | CPT 59025 | $87 |
| Vaginal delivery only | CPT 59409 | $3,194.07 |
| Office visit, established patient, 5 min | CPT 99211 | $87.2 |
| Office visit, established patient, 10-19 min | CPT 99212 | $82.75 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $82.75 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $36,006 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,280 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,847 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,913 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,436 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,960 |
| Major joint replacement w MCC | MS-DRG 469 | $24,117 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,718 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,197 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,978 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,452 |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,008 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,219 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,520 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,484 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,632 |
| PCI single major coronary artery | CPT 92920 | $5,615.88 |
| PCI with drug-eluting stent | CPT 92928 | $11,391 |
| PCI bypass graft | CPT 92937 | $11,391 |
| Left heart catheterization | CPT 93452 | $3,198.82 |
| Coronary angiography with cath | CPT 93455 | $3,198.82 |
| Coronary angiography with bypass cath | CPT 93458 | $3,198.82 |
