| Psychoses | MS-DRG 885 | $2,356.00 |
| CT head without contrast | CPT 70450 | $294.45 |
| CT head with contrast | CPT 70460 | $3,525.04 |
| CT head with and without contrast | CPT 70470 | $472.62 |
| CT neck with contrast | CPT 70491 | $248.83 |
| MRI brain without contrast | CPT 70551 | $630.30 |
| MRI brain with contrast | CPT 70552 | $3,642.10 |
| MRI brain with and without contrast | CPT 70553 | $994.64 |
| Chest X-ray single view | CPT 71045 | $176.25 |
| Chest X-ray 2 views | CPT 71046 | $218.59 |
| Chest X-ray 3 views | CPT 71047 | $454.37 |
| CT chest without contrast | CPT 71250 | $294.45 |
| CT chest with contrast | CPT 71260 | $326.09 |
| CT chest with and without contrast | CPT 71270 | $2,916.39 |
| MRI chest without contrast | CPT 71550 | $2,110.66 |
| MRI chest with contrast | CPT 71551 | $3,147.60 |
| MRI chest with and without contrast | CPT 71552 | $3,577.29 |
| Lumbosacral spine X-ray | CPT 72100 | $338.08 |
| CT cervical spine without contrast | CPT 72125 | $294.45 |
| CT thoracic spine without contrast | CPT 72128 | $326.09 |
| CT lumbar spine without contrast | CPT 72131 | $338.08 |
| MRI cervical spine without contrast | CPT 72141 | $621.80 |
| MRI thoracic spine without contrast | CPT 72146 | $686.17 |
| MRI lumbar spine without contrast | CPT 72148 | $621.80 |
| MRI lumbar spine with and without contrast | CPT 72149 | $5,914.59 |
| MRI cervical spine with and without contrast | CPT 72156 | $994.64 |
| MRI lumbar spine with contrast | CPT 72158 | $994.64 |
| CT pelvis without contrast | CPT 72192 | $338.08 |
| CT pelvis with contrast | CPT 72193 | $746.48 |
| Shoulder X-ray | CPT 73030 | $233.73 |
| Humerus X-ray | CPT 73060 | $218.59 |
| Hand X-ray 3 views | CPT 73130 | $233.73 |
| MRI upper extremity joint without contrast | CPT 73221 | $733.26 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,297.58 |
| Knee X-ray 1-2 views | CPT 73560 | $214.12 |
| Ankle X-ray 3 views | CPT 73610 | $218.59 |
| MRI lower extremity joint without contrast | CPT 73721 | $630.30 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $829.11 |
| CT abdomen without contrast | CPT 74150 | $294.45 |
| CT abdomen with contrast | CPT 74160 | $791.32 |
| CT abdomen with and without contrast | CPT 74170 | $6,371.64 |
| CT abdomen and pelvis without contrast | CPT 74176 | $630.05 |
| CT abdomen and pelvis with contrast | CPT 74177 | $994.64 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $746.48 |
| MRI abdomen without contrast | CPT 74181 | $3,290.19 |
| MRI abdomen with and without contrast | CPT 74183 | $5,385.09 |
| Abdominal ultrasound complete | CPT 76700 | $338.08 |
| Abdominal ultrasound limited | CPT 76705 | $294.45 |
| Retroperitoneal ultrasound complete | CPT 76770 | $338.08 |
| Obstetric ultrasound first trimester | CPT 76801 | $771.14 |
| Obstetric ultrasound after first trimester | CPT 76805 | $886.71 |
| Transvaginal ultrasound | CPT 76830 | $945.03 |
| Pelvic ultrasound complete | CPT 76856 | $858.52 |
| Scrotal ultrasound | CPT 76870 | $338.08 |
| Diagnostic mammography bilateral | CPT 77066 | $471.83 |
| Screening mammography bilateral | CPT 77067 | $206.97 |
| EKG complete | CPT 93000 | $504.49 |
| EKG tracing only | CPT 93005 | $286.86 |
| Transthoracic echocardiogram complete | CPT 93306 | $969.23 |
| Transthoracic echocardiogram | CPT 93307 | $1,235.97 |
| Stress echocardiogram | CPT 93350 | $1,307.26 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $2,356.00 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $2,356.00 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $2,356.00 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $2,356.00 |
| COPD w MCC | MS-DRG 190 | $2,356.00 |
| COPD w CC | MS-DRG 191 | $2,356.00 |
| COPD w/o CC/MCC | MS-DRG 192 | $2,356.00 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $2,356.00 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $2,356.00 |
| AMI discharged alive w MCC | MS-DRG 280 | $2,356.00 |
| AMI discharged alive w CC | MS-DRG 281 | $2,356.00 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $2,356.00 |
| Heart failure & shock w MCC | MS-DRG 291 | $2,356.00 |
| Heart failure & shock w CC | MS-DRG 292 | $2,356.00 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $2,356.00 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $2,356.00 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $2,356.00 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $2,356.00 |
| GI hemorrhage w CC | MS-DRG 378 | $2,356.00 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $2,356.00 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $2,356.00 |
| Fractures of femur w/o MCC | MS-DRG 533 | $2,356.00 |
| Kidney/UTI w MCC | MS-DRG 689 | $2,356.00 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $2,356.00 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $2,356.00 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $2,356.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $35.60 |
| Electrolyte panel | CPT 80051 | $139.45 |
| Comprehensive metabolic panel | CPT 80053 | $44.47 |
| Lipid panel | CPT 80061 | $51.08 |
| Renal function panel | CPT 80069 | $33.12 |
| Hepatic function panel | CPT 80076 | $31.18 |
| Urinalysis non-automated | CPT 81002 | $32.48 |
| Urinalysis automated | CPT 81003 | $12.11 |
| Glucose quantitative | CPT 82947 | $50.93 |
| Hemoglobin A1c | CPT 83036 | $40.85 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $207.03 |
| Complete blood count with automated differential | CPT 85025 | $32.72 |
| Complete blood count without differential | CPT 85027 | $24.66 |
| Urine culture bacterial | CPT 87086 | $30.78 |
| Urine culture identification | CPT 87088 | $23.45 |
| Tissue exam by pathologist level IV | CPT 88305 | $387.28 |
| Office visit, new patient, 45-59 min | CPT 99204 | $1,904.52 |
| Office visit, new patient, 60-74 min | CPT 99205 | $1,868.43 |
| Office visit, established patient, 5 min | CPT 99211 | $187.54 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $172.11 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $752.58 |
| Office visit, established patient, 40-54 min | CPT 99215 | $385.76 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $2,356.00 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $2,356.00 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $2,356.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $2,356.00 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $2,356.00 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $2,356.00 |
| Major joint replacement w MCC | MS-DRG 469 | $2,356.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $2,356.00 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $2,356.00 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $2,356.00 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $2,356.00 |
| OR procedure for obesity w MCC | MS-DRG 619 | $2,356.00 |
| OR procedure for obesity w CC | MS-DRG 620 | $2,356.00 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $2,356.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $2,356.00 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $2,356.00 |
