| Psychoses | MS-DRG 885 | $13,601 |
| Psychiatric eval with medical services | CPT 90792 | $156.78 |
| ED visit level 1 | CPT 99281 | $251.30 |
| ED visit level 2 | CPT 99282 | $421.22 |
| ED visit level 3 | CPT 99283 | $777.33 |
| ED visit level 4 | CPT 99284 | $1,388.31 |
| ED visit level 5 | CPT 99285 | $1,970.71 |
| Critical care, first hour | CPT 99291 | $1,208.47 |
| CT head without contrast | CPT 70450 | $963.79 |
| CT head with contrast | CPT 70460 | $1,353.17 |
| CT head with and without contrast | CPT 70470 | $1,589.91 |
| CT neck with contrast | CPT 70491 | $1,268.65 |
| MRI brain without contrast | CPT 70551 | $1,221.13 |
| MRI brain with contrast | CPT 70552 | $2,287.94 |
| MRI brain with and without contrast | CPT 70553 | $2,287.10 |
| Chest X-ray single view | CPT 71045 | $140.03 |
| Chest X-ray 2 views | CPT 71046 | $174.09 |
| CT chest without contrast | CPT 71250 | $572.72 |
| CT chest with contrast | CPT 71260 | $1,242.58 |
| CT chest with and without contrast | CPT 71270 | $1,140.82 |
| MRI chest without contrast | CPT 71550 | $1,211.04 |
| MRI chest with and without contrast | CPT 71552 | $1,996.54 |
| Lumbosacral spine X-ray | CPT 72100 | $222.87 |
| CT cervical spine without contrast | CPT 72125 | $1,134.51 |
| CT thoracic spine without contrast | CPT 72128 | $1,002.90 |
| CT lumbar spine without contrast | CPT 72131 | $812.83 |
| MRI cervical spine without contrast | CPT 72141 | $1,310.70 |
| MRI thoracic spine without contrast | CPT 72146 | $1,338.45 |
| MRI lumbar spine without contrast | CPT 72148 | $1,352.75 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,154.22 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,559.64 |
| MRI lumbar spine with contrast | CPT 72158 | $2,344.29 |
| CT pelvis without contrast | CPT 72192 | $621.08 |
| CT pelvis with contrast | CPT 72193 | $1,216.93 |
| Shoulder X-ray | CPT 73030 | $179.98 |
| Humerus X-ray | CPT 73060 | $145.08 |
| Hand X-ray 3 views | CPT 73130 | $167.78 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,457.88 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,799.69 |
| Knee X-ray 1-2 views | CPT 73560 | $216.98 |
| Ankle X-ray 3 views | CPT 73610 | $162.32 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,452.83 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,795.49 |
| CT abdomen without contrast | CPT 74150 | $1,189.18 |
| CT abdomen with contrast | CPT 74160 | $1,573.93 |
| CT abdomen with and without contrast | CPT 74170 | $1,736.25 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,766.94 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,491.89 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,797.59 |
| MRI abdomen without contrast | CPT 74181 | $1,118.53 |
| MRI abdomen with and without contrast | CPT 74183 | $2,070.54 |
| Abdominal ultrasound complete | CPT 76700 | $433.69 |
| Abdominal ultrasound limited | CPT 76705 | $323.78 |
| Retroperitoneal ultrasound complete | CPT 76770 | $385.74 |
| Obstetric ultrasound first trimester | CPT 76801 | $250.79 |
| Obstetric ultrasound after first trimester | CPT 76805 | $244.43 |
| Transvaginal ultrasound | CPT 76830 | $370.46 |
| Pelvic ultrasound complete | CPT 76856 | $530.44 |
| Scrotal ultrasound | CPT 76870 | $403.14 |
| Diagnostic mammography unilateral | CPT 77065 | $286.64 |
| Diagnostic mammography bilateral | CPT 77066 | $398.19 |
| Screening mammography bilateral | CPT 77067 | $182.12 |
| EKG tracing only | CPT 93005 | $163.17 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,366.25 |
| Stress echocardiogram | CPT 93350 | $920.39 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $19,193 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $9,811.63 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,641.11 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,597 |
| COPD w MCC | MS-DRG 190 | $10,835 |
| COPD w CC | MS-DRG 191 | $8,289.09 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,244.55 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,911.83 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,008.16 |
| AMI discharged alive w MCC | MS-DRG 280 | $15,837 |
| AMI discharged alive w CC | MS-DRG 281 | $8,894.05 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,996.18 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,589 |
| Heart failure & shock w CC | MS-DRG 292 | $8,309.35 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,294.17 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,635 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,133.19 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,398.37 |
| GI hemorrhage w CC | MS-DRG 378 | $9,512.53 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,143.24 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,528.78 |
| Fractures of femur w/o MCC | MS-DRG 533 | $14,713 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,292 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,743.94 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,931 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,947.68 |
| Basic metabolic panel (BMP) | CPT 80048 | $123.47 |
| General health panel | CPT 80050 | $16.62 |
| Electrolyte panel | CPT 80051 | $54.79 |
| Comprehensive metabolic panel | CPT 80053 | $181.03 |
| Lipid panel | CPT 80061 | $115.93 |
| Renal function panel | CPT 80069 | $95.28 |
| Hepatic function panel | CPT 80076 | $138.16 |
| Urinalysis non-automated | CPT 81002 | $14.69 |
| Urinalysis automated | CPT 81003 | $28.98 |
| Glucose quantitative | CPT 82947 | $9.93 |
| Hemoglobin A1c | CPT 83036 | $68.29 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $80.20 |
| Complete blood count with automated differential | CPT 85025 | $70.27 |
| Complete blood count without differential | CPT 85027 | $50.02 |
| Urine culture bacterial | CPT 87086 | $17.87 |
| Urine culture identification | CPT 87088 | $28.59 |
| Tissue exam by pathologist level IV | CPT 88305 | $191.36 |
| Fetal non-stress test | CPT 59025 | $170.54 |
| Vaginal delivery only | CPT 59409 | $2,679.74 |
| Sigmoidoscopy diagnostic | CPT 45330 | $735.46 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $40,820 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $38,815 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $44,305 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $22,806 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,930 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,001 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,713 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $34,055 |
| Major joint replacement w MCC | MS-DRG 469 | $31,538 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,192 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,376 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,020 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,306 |
| OR procedure for obesity w MCC | MS-DRG 619 | $26,307 |
| OR procedure for obesity w CC | MS-DRG 620 | $15,409 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,104 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,566 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,853 |
| PCI single major coronary artery | CPT 92920 | $8,150.50 |
| PCI with drug-eluting stent | CPT 92928 | $11,675 |
| PCI bypass graft | CPT 92937 | $11,855 |
| Left heart catheterization | CPT 93452 | $2,114.75 |
| Coronary angiography with cath | CPT 93455 | $6,602.51 |
| Coronary angiography with bypass cath | CPT 93458 | $7,916.43 |
