| Psychoses | MS-DRG 885 | $75.00 |
| ED visit level 1 | CPT 99281 | $288.96 |
| ED visit level 2 | CPT 99282 | $622.64 |
| ED visit level 3 | CPT 99283 | $1,016.74 |
| ED visit level 4 | CPT 99284 | $1,447.63 |
| ED visit level 5 | CPT 99285 | $2,007.27 |
| Critical care, first hour | CPT 99291 | $2,517.45 |
| CT head without contrast | CPT 70450 | $872.27 |
| CT head with contrast | CPT 70460 | $1,385.68 |
| CT head with and without contrast | CPT 70470 | $1,506.05 |
| CT neck with contrast | CPT 70491 | $188.16 |
| MRI brain without contrast | CPT 70551 | $1,406.58 |
| MRI brain with contrast | CPT 70552 | $2,286.05 |
| MRI brain with and without contrast | CPT 70553 | $3,057.60 |
| Chest X-ray single view | CPT 71045 | $92.61 |
| Chest X-ray 2 views | CPT 71046 | $93.35 |
| Chest X-ray 3 views | CPT 71047 | $376.35 |
| CT chest without contrast | CPT 71250 | $112.15 |
| CT chest with contrast | CPT 71260 | — |
| CT chest with and without contrast | CPT 71270 | $1,468.20 |
| MRI chest without contrast | CPT 71550 | $1,503.05 |
| MRI chest with and without contrast | CPT 71552 | $2,204.15 |
| Lumbosacral spine X-ray | CPT 72100 | $112.15 |
| CT cervical spine without contrast | CPT 72125 | $1,107.23 |
| CT thoracic spine without contrast | CPT 72128 | $979.02 |
| CT lumbar spine without contrast | CPT 72131 | $935.63 |
| MRI cervical spine without contrast | CPT 72141 | $2,761.85 |
| MRI thoracic spine without contrast | CPT 72146 | $1,430.72 |
| MRI lumbar spine without contrast | CPT 72148 | $2,858.70 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,001.70 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,044.60 |
| MRI lumbar spine with contrast | CPT 72158 | $3,151.85 |
| CT pelvis without contrast | CPT 72192 | — |
| CT pelvis with contrast | CPT 72193 | $1,329.83 |
| Shoulder X-ray | CPT 73030 | — |
| Humerus X-ray | CPT 73060 | — |
| Hand X-ray 3 views | CPT 73130 | $388.84 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,838.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,344.32 |
| Knee X-ray 1-2 views | CPT 73560 | $321.90 |
| Ankle X-ray 3 views | CPT 73610 | — |
| MRI lower extremity joint without contrast | CPT 73721 | $1,733.60 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,308.60 |
| CT abdomen without contrast | CPT 74150 | $989.54 |
| CT abdomen with contrast | CPT 74160 | $1,188.76 |
| CT abdomen with and without contrast | CPT 74170 | $1,708.85 |
| CT abdomen and pelvis without contrast | CPT 74176 | $255.96 |
| CT abdomen and pelvis with contrast | CPT 74177 | — |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,933.80 |
| MRI abdomen without contrast | CPT 74181 | $1,583.26 |
| MRI abdomen with and without contrast | CPT 74183 | $3,021.85 |
| Abdominal ultrasound complete | CPT 76700 | $1,011.50 |
| Abdominal ultrasound limited | CPT 76705 | $923.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $533.04 |
| Obstetric ultrasound first trimester | CPT 76801 | $761.80 |
| Obstetric ultrasound after first trimester | CPT 76805 | $975.65 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,122.55 |
| Transvaginal ultrasound | CPT 76830 | $753.35 |
| Pelvic ultrasound complete | CPT 76856 | $535.04 |
| Scrotal ultrasound | CPT 76870 | $861.90 |
| Diagnostic mammography unilateral | CPT 77065 | $322.46 |
| Diagnostic mammography bilateral | CPT 77066 | $449.55 |
| Screening mammography bilateral | CPT 77067 | $313.96 |
| EKG tracing only | CPT 93005 | $182.07 |
| Transthoracic echocardiogram complete | CPT 93306 | $4,372.34 |
| Transthoracic echocardiogram | CPT 93307 | $858.70 |
| Stress echocardiogram | CPT 93350 | $3,720.59 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $75.00 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $74.30 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $74.30 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $75.00 |
| COPD w MCC | MS-DRG 190 | $75.00 |
| COPD w CC | MS-DRG 191 | $75.00 |
| COPD w/o CC/MCC | MS-DRG 192 | $75.00 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $75.00 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $75.00 |
| AMI discharged alive w MCC | MS-DRG 280 | $75.00 |
| AMI discharged alive w CC | MS-DRG 281 | $75.00 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $75.00 |
| Heart failure & shock w MCC | MS-DRG 291 | $75.00 |
| Heart failure & shock w CC | MS-DRG 292 | $75.00 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $75.00 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $75.00 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $75.00 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $75.00 |
| GI hemorrhage w CC | MS-DRG 378 | $75.00 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $75.00 |
| Kidney/UTI w MCC | MS-DRG 689 | $75.00 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $75.00 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $75.00 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $75.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $123.03 |
| General health panel | CPT 80050 | $260.65 |
| Electrolyte panel | CPT 80051 | $39.90 |
| Comprehensive metabolic panel | CPT 80053 | $24.97 |
| Lipid panel | CPT 80061 | $31.67 |
| Renal function panel | CPT 80069 | $59.19 |
| Hepatic function panel | CPT 80076 | $101.87 |
| Urinalysis non-automated | CPT 81002 | $8.80 |
| Urinalysis automated | CPT 81003 | — |
| Glucose quantitative | CPT 82947 | $77.81 |
| Hemoglobin A1c | CPT 83036 | — |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $100.51 |
| Complete blood count with automated differential | CPT 85025 | $51.14 |
| Complete blood count without differential | CPT 85027 | $94.25 |
| Urine culture bacterial | CPT 87086 | $19.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $442.87 |
| Fetal non-stress test | CPT 59025 | $586.95 |
| Vaginal delivery only | CPT 59409 | $1,757.48 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,552.62 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,744.29 |
| Sigmoidoscopy diagnostic | CPT 45330 | $75.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $75.00 |
| Colonoscopy diagnostic | CPT 45378 | $2,658.69 |
| Colonoscopy with biopsy | CPT 45380 | $2,891.58 |
| Colonoscopy with polyp removal | CPT 45385 | $3,643.85 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $75.00 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $75.00 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $75.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $75.00 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $75.00 |
| Major joint replacement w MCC | MS-DRG 469 | $75.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $75.00 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $75.00 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $75.00 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $75.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $75.00 |
| PCI single major coronary artery | CPT 92920 | — |
| PCI with drug-eluting stent | CPT 92928 | $75.00 |
| PCI bypass graft | CPT 92937 | $10,417 |
| Left heart catheterization | CPT 93452 | $74.30 |
| Coronary angiography with cath | CPT 93455 | $75.00 |
| Coronary angiography with bypass cath | CPT 93458 | $9,328.03 |
