| Psychoses | MS-DRG 885 | $10,478 |
| ED visit level 1 | CPT 99281 | $136.88 |
| ED visit level 2 | CPT 99282 | $203.1 |
| ED visit level 3 | CPT 99283 | $339.53 |
| ED visit level 4 | CPT 99284 | $564.23 |
| ED visit level 5 | CPT 99285 | $1,025.04 |
| Critical care, first hour | CPT 99291 | $978.03 |
| CT head without contrast | CPT 70450 | $287.23 |
| CT head with contrast | CPT 70460 | $461.28 |
| CT head with and without contrast | CPT 70470 | $461.28 |
| CT neck with contrast | CPT 70491 | $461.28 |
| MRI brain without contrast | CPT 70551 | $622.23 |
| MRI brain with and without contrast | CPT 70553 | $699.53 |
| Chest X-ray single view | CPT 71045 | $86.89 |
| Chest X-ray 2 views | CPT 71046 | $87.1 |
| CT chest without contrast | CPT 71250 | $287.23 |
| CT chest with contrast | CPT 71260 | $461.28 |
| CT chest with and without contrast | CPT 71270 | $461.28 |
| MRI chest without contrast | CPT 71550 | $622.23 |
| MRI chest with and without contrast | CPT 71552 | $699.53 |
| Lumbosacral spine X-ray | CPT 72100 | $106.92 |
| CT cervical spine without contrast | CPT 72125 | $287.23 |
| CT thoracic spine without contrast | CPT 72128 | $287.23 |
| CT lumbar spine without contrast | CPT 72131 | $287.23 |
| MRI cervical spine without contrast | CPT 72141 | $622.23 |
| MRI thoracic spine without contrast | CPT 72146 | $622.23 |
| MRI lumbar spine without contrast | CPT 72148 | $622.23 |
| MRI cervical spine with and without contrast | CPT 72156 | $699.53 |
| MRI lumbar spine with contrast | CPT 72158 | $699.53 |
| CT pelvis without contrast | CPT 72192 | $287.23 |
| CT pelvis with contrast | CPT 72193 | $461.28 |
| Shoulder X-ray | CPT 73030 | $90.03 |
| Humerus X-ray | CPT 73060 | $89.35 |
| Hand X-ray 3 views | CPT 73130 | $90.03 |
| MRI upper extremity joint without contrast | CPT 73221 | $622.23 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $699.53 |
| Knee X-ray 1-2 views | CPT 73560 | $90.03 |
| Ankle X-ray 3 views | CPT 73610 | $90.03 |
| MRI lower extremity joint without contrast | CPT 73721 | $622.23 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $699.53 |
| CT abdomen without contrast | CPT 74150 | $287.23 |
| CT abdomen with contrast | CPT 74160 | $461.28 |
| CT abdomen with and without contrast | CPT 74170 | $461.28 |
| CT abdomen and pelvis without contrast | CPT 74176 | $495.23 |
| CT abdomen and pelvis with contrast | CPT 74177 | $572.53 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $572.53 |
| MRI abdomen without contrast | CPT 74181 | $622.23 |
| MRI abdomen with and without contrast | CPT 74183 | $699.53 |
| Abdominal ultrasound complete | CPT 76700 | $180.4 |
| Abdominal ultrasound limited | CPT 76705 | $180.4 |
| Retroperitoneal ultrasound complete | CPT 76770 | $285.14 |
| Obstetric ultrasound first trimester | CPT 76801 | $180.4 |
| Obstetric ultrasound after first trimester | CPT 76805 | $180.4 |
| Transvaginal ultrasound | CPT 76830 | $208.73 |
| Pelvic ultrasound complete | CPT 76856 | $248.63 |
| Scrotal ultrasound | CPT 76870 | $180.4 |
| Diagnostic mammography unilateral | CPT 77065 | $222.58 |
| Diagnostic mammography bilateral | CPT 77066 | $298.93 |
| Screening mammography bilateral | CPT 77067 | $256.98 |
| EKG tracing only | CPT 93005 | $62.41 |
| Transthoracic echocardiogram complete | CPT 93306 | $590.77 |
| Stress echocardiogram | CPT 93350 | $647.43 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,015 |
| COPD w MCC | MS-DRG 190 | $8,516.88 |
| COPD w CC | MS-DRG 191 | $6,481.65 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,516.88 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,196.4 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,832.4 |
| AMI discharged alive w MCC | MS-DRG 280 | $12,334 |
| AMI discharged alive w CC | MS-DRG 281 | $7,066.77 |
| Heart failure & shock w MCC | MS-DRG 291 | $9,870.87 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,257.31 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,656.65 |
| GI hemorrhage w CC | MS-DRG 378 | $7,540.39 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,847.02 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,994.18 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,921.31 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,224.07 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $14,935 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $82.27 |
| Basic metabolic panel (BMP) | CPT 80048 | $9.14 |
| General health panel | CPT 80050 | $51.03 |
| Electrolyte panel | CPT 80051 | $7.57 |
| Comprehensive metabolic panel | CPT 80053 | $11.4 |
| Lipid panel | CPT 80061 | $14.45 |
| Renal function panel | CPT 80069 | $9.37 |
| Hepatic function panel | CPT 80076 | $8.82 |
| Urinalysis automated | CPT 81003 | $2.43 |
| Glucose quantitative | CPT 82947 | $4.25 |
| Hemoglobin A1c | CPT 83036 | $10.48 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $18.14 |
| Complete blood count with automated differential | CPT 85025 | $8.39 |
| Complete blood count without differential | CPT 85027 | $7.27 |
| Urine culture bacterial | CPT 87086 | $8.71 |
| Urine culture identification | CPT 87088 | $8.74 |
| Tissue exam by pathologist level IV | CPT 88305 | $76.16 |
| Fetal non-stress test | CPT 59025 | $276.21 |
| Office visit, new patient, 15-29 min | CPT 99202 | $121.47 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $219.45 |
| Office visit, new patient, 45-59 min | CPT 99204 | $285.29 |
| Office visit, new patient, 60-74 min | CPT 99205 | $381.34 |
| Office visit, established patient, 5 min | CPT 99211 | $17.44 |
| Office visit, established patient, 10-19 min | CPT 99212 | $139.77 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $445.73 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $196.69 |
| Office visit, established patient, 40-54 min | CPT 99215 | $307.41 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,068.01 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,068.01 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,038.76 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,038.76 |
| Colonoscopy diagnostic | CPT 45378 | $1,038.76 |
| Colonoscopy with biopsy | CPT 45380 | $1,343.3 |
| Colonoscopy with polyp removal | CPT 45385 | $1,343.3 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $35,342 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $18,432 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $12,939 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,006 |
| Major joint replacement w/o MCC | MS-DRG 470 | $14,831 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,392 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,104 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,539.48 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $15,755 |
