| ED visit level 1 | CPT 99281 | $131 |
| ED visit level 2 | CPT 99282 | $237 |
| ED visit level 3 | CPT 99283 | $360 |
| ED visit level 4 | CPT 99284 | $521 |
| ED visit level 5 | CPT 99285 | $673.78 |
| Critical care, first hour | CPT 99291 | $926.01 |
| CT head without contrast | CPT 70450 | $194.73 |
| CT head with contrast | CPT 70460 | $322.54 |
| CT head with and without contrast | CPT 70470 | $322.54 |
| CT neck with contrast | CPT 70491 | $322.54 |
| MRI brain without contrast | CPT 70551 | $430.15 |
| MRI brain with contrast | CPT 70552 | $664.88 |
| MRI brain with and without contrast | CPT 70553 | $664.88 |
| Chest X-ray single view | CPT 71045 | $160.94 |
| Chest X-ray 2 views | CPT 71046 | $160.94 |
| Chest X-ray 3 views | CPT 71047 | $158.09 |
| CT chest without contrast | CPT 71250 | $194.73 |
| CT chest with contrast | CPT 71260 | $322.54 |
| CT chest with and without contrast | CPT 71270 | $322.54 |
| MRI chest without contrast | CPT 71550 | $430.15 |
| MRI chest with and without contrast | CPT 71552 | $664.88 |
| Lumbosacral spine X-ray | CPT 72100 | $194.73 |
| CT cervical spine without contrast | CPT 72125 | $194.73 |
| CT thoracic spine without contrast | CPT 72128 | $194.73 |
| CT lumbar spine without contrast | CPT 72131 | $194.73 |
| MRI cervical spine without contrast | CPT 72141 | $430.15 |
| MRI thoracic spine without contrast | CPT 72146 | $430.15 |
| MRI lumbar spine without contrast | CPT 72148 | $430.15 |
| MRI lumbar spine with and without contrast | CPT 72149 | $526.58 |
| MRI cervical spine with and without contrast | CPT 72156 | $664.88 |
| MRI lumbar spine with contrast | CPT 72158 | $664.88 |
| CT pelvis without contrast | CPT 72192 | $194.73 |
| CT pelvis with contrast | CPT 72193 | $322.54 |
| Shoulder X-ray | CPT 73030 | $466.53 |
| Humerus X-ray | CPT 73060 | $431.61 |
| Hand X-ray 3 views | CPT 73130 | $403.68 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,904.52 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $664.88 |
| Knee X-ray 1-2 views | CPT 73560 | $483.24 |
| Ankle X-ray 3 views | CPT 73610 | $410.66 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,071.01 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $664.88 |
| CT abdomen without contrast | CPT 74150 | $194.73 |
| CT abdomen with contrast | CPT 74160 | $257.65 |
| CT abdomen with and without contrast | CPT 74170 | $322.54 |
| CT abdomen and pelvis without contrast | CPT 74176 | $430.15 |
| CT abdomen and pelvis with contrast | CPT 74177 | $639.34 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $639.34 |
| MRI abdomen without contrast | CPT 74181 | $430.15 |
| MRI abdomen with and without contrast | CPT 74183 | $664.88 |
| Abdominal ultrasound complete | CPT 76700 | $193.01 |
| Abdominal ultrasound limited | CPT 76705 | $153.98 |
| Retroperitoneal ultrasound complete | CPT 76770 | $155.06 |
| Obstetric ultrasound first trimester | CPT 76801 | $191.29 |
| Obstetric ultrasound after first trimester | CPT 76805 | $194.73 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $265.65 |
| Transvaginal ultrasound | CPT 76830 | $133.42 |
| Pelvic ultrasound complete | CPT 76856 | $160.83 |
| Scrotal ultrasound | CPT 76870 | $166.2 |
| Screening mammography bilateral | CPT 77067 | $123.08 |
| EKG tracing only | CPT 93005 | $67.07 |
| Transthoracic echocardiogram complete | CPT 93306 | $925.12 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,163 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,754.02 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,143.02 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,571 |
| COPD w MCC | MS-DRG 190 | $9,597.07 |
| COPD w CC | MS-DRG 191 | $7,500.17 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,051.23 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,621.78 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,452 |
| AMI discharged alive w CC | MS-DRG 281 | $7,844.54 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,435.42 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,042 |
| Heart failure & shock w CC | MS-DRG 292 | $7,516.85 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,033.79 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,256 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,548.25 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,119.61 |
| GI hemorrhage w CC | MS-DRG 378 | $8,344.08 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,874.04 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,972.9 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,051.23 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,952 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,866.06 |
| Basic metabolic panel (BMP) | CPT 80048 | $9 |
| Electrolyte panel | CPT 80051 | $7.46 |
| Comprehensive metabolic panel | CPT 80053 | $11.23 |
| Lipid panel | CPT 80061 | $31.5 |
| Renal function panel | CPT 80069 | $9.23 |
| Hepatic function panel | CPT 80076 | $8.69 |
| Urinalysis non-automated | CPT 81002 | $3.58 |
| Urinalysis automated | CPT 81003 | $2.33 |
| Glucose quantitative | CPT 82947 | $7.5 |
| Hemoglobin A1c | CPT 83036 | $10.05 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $23.44 |
| Complete blood count with automated differential | CPT 85025 | $12.11 |
| Complete blood count without differential | CPT 85027 | $6.7 |
| Urine culture bacterial | CPT 87086 | $8.35 |
| Tissue exam by pathologist level IV | CPT 88305 | $99.95 |
| Fetal non-stress test | CPT 59025 | $226.1 |
| Vaginal delivery only | CPT 59409 | $3,574.58 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $36,446 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,081 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,860 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,922 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,143 |
| Major joint replacement w MCC | MS-DRG 469 | $26,134 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,656 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,580 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,831 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,318 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,199 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,200 |
| PCI single major coronary artery | CPT 92920 | $5,998.24 |
| PCI with drug-eluting stent | CPT 92928 | $11,816 |
| PCI bypass graft | CPT 92937 | $11,816 |
| Coronary angiography with cath | CPT 93455 | $3,534.77 |
| Coronary angiography with bypass cath | CPT 93458 | $3,534.77 |
