| Psychoses | MS-DRG 885 | $10,183 |
| ED visit level 1 | CPT 99281 | $332.77 |
| ED visit level 2 | CPT 99282 | $637.68 |
| ED visit level 3 | CPT 99283 | $1,109.23 |
| ED visit level 4 | CPT 99284 | $1,886.22 |
| ED visit level 5 | CPT 99285 | $2,773.60 |
| Critical care, first hour | CPT 99291 | $4,437.44 |
| CT head without contrast | CPT 70450 | $1,085.50 |
| CT head with contrast | CPT 70460 | $1,085.50 |
| CT head with and without contrast | CPT 70470 | $1,085.50 |
| CT neck with contrast | CPT 70491 | $1,085.50 |
| Chest X-ray single view | CPT 71045 | $723.28 |
| Chest X-ray 2 views | CPT 71046 | $897.11 |
| Chest X-ray 3 views | CPT 71047 | $359.78 |
| CT chest without contrast | CPT 71250 | $1,085.50 |
| CT chest with contrast | CPT 71260 | $1,085.50 |
| CT chest with and without contrast | CPT 71270 | $1,085.50 |
| Lumbosacral spine X-ray | CPT 72100 | $714.50 |
| CT cervical spine without contrast | CPT 72125 | $1,085.50 |
| CT thoracic spine without contrast | CPT 72128 | $1,085.50 |
| CT lumbar spine without contrast | CPT 72131 | $1,085.50 |
| CT pelvis without contrast | CPT 72192 | $1,085.50 |
| CT pelvis with contrast | CPT 72193 | $1,085.50 |
| Shoulder X-ray | CPT 73030 | $843.63 |
| Humerus X-ray | CPT 73060 | $272.39 |
| Hand X-ray 3 views | CPT 73130 | $812.63 |
| Knee X-ray 1-2 views | CPT 73560 | $658.25 |
| Ankle X-ray 3 views | CPT 73610 | $988.89 |
| CT abdomen without contrast | CPT 74150 | $1,085.50 |
| CT abdomen with contrast | CPT 74160 | $1,085.50 |
| CT abdomen with and without contrast | CPT 74170 | $1,085.50 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,085.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,085.50 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,085.50 |
| Abdominal ultrasound complete | CPT 76700 | $1,087.50 |
| Abdominal ultrasound limited | CPT 76705 | $822.33 |
| Retroperitoneal ultrasound complete | CPT 76770 | $1,021.62 |
| Obstetric ultrasound first trimester | CPT 76801 | $755.63 |
| Obstetric ultrasound after first trimester | CPT 76805 | $868.88 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $300.14 |
| Transvaginal ultrasound | CPT 76830 | $546.75 |
| Pelvic ultrasound complete | CPT 76856 | $992.31 |
| Scrotal ultrasound | CPT 76870 | $953.50 |
| Diagnostic mammography unilateral | CPT 77065 | $206.25 |
| Diagnostic mammography bilateral | CPT 77066 | $412.50 |
| Screening mammography bilateral | CPT 77067 | $300.00 |
| EKG tracing only | CPT 93005 | $61.05 |
| Transthoracic echocardiogram complete | CPT 93306 | $529.60 |
| Transthoracic echocardiogram | CPT 93307 | $252.39 |
| Stress echocardiogram | CPT 93350 | $529.60 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $14,429 |
| COPD w MCC | MS-DRG 190 | $9,392.59 |
| COPD w CC | MS-DRG 191 | $7,711.48 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,397.59 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,571.15 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,188.84 |
| AMI discharged alive w MCC | MS-DRG 280 | $12,899 |
| AMI discharged alive w CC | MS-DRG 281 | $8,053.56 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,611.22 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,908 |
| Heart failure & shock w CC | MS-DRG 292 | $7,795.25 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,102.28 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,918.98 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,778.07 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,444.63 |
| GI hemorrhage w CC | MS-DRG 378 | $8,480.12 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,994.06 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,882.79 |
| Fractures of femur w/o MCC | MS-DRG 533 | $11,408 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,304.62 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,076.87 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $14,589 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,678.39 |
| Basic metabolic panel (BMP) | CPT 80048 | $14.30 |
| General health panel | CPT 80050 | $69.75 |
| Electrolyte panel | CPT 80051 | $11.84 |
| Comprehensive metabolic panel | CPT 80053 | $713.26 |
| Lipid panel | CPT 80061 | $39.89 |
| Renal function panel | CPT 80069 | $14.67 |
| Hepatic function panel | CPT 80076 | $13.81 |
| Urinalysis non-automated | CPT 81002 | $5.29 |
| Urinalysis automated | CPT 81003 | $3.79 |
| Glucose quantitative | CPT 82947 | $6.65 |
| Hemoglobin A1c | CPT 83036 | $23.25 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $549.68 |
| Complete blood count with automated differential | CPT 85025 | $13.13 |
| Complete blood count without differential | CPT 85027 | $10.93 |
| Urine culture bacterial | CPT 87086 | $13.65 |
| Urine culture identification | CPT 87088 | $13.67 |
| Tissue exam by pathologist level IV | CPT 88305 | $90.17 |
| Fetal non-stress test | CPT 59025 | $188.64 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,031.86 |
| Vaginal delivery only | CPT 59409 | $2,848.44 |
| Vaginal delivery with postpartum | CPT 59410 | $2,023.00 |
| Routine obstetric care with C-section | CPT 59510 | $2,247.10 |
| C-section delivery only | CPT 59514 | $2,023.00 |
| C-section with postpartum | CPT 59515 | $2,892.00 |
| Office visit, established patient, 5 min | CPT 99211 | $226.24 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,315.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,729.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,097.02 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,315.00 |
| Colonoscopy diagnostic | CPT 45378 | $1,729.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,729.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,729.00 |
| Total shoulder arthroplasty | CPT 23472 | $13,278 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $23,368 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $15,427 |
| Hip hemiarthroplasty | CPT 27125 | $2,980.71 |
| Total hip replacement | CPT 27130 | $13,183 |
| Total knee replacement | CPT 27447 | $13,183 |
| Knee revision arthroplasty single component | CPT 27486 | $13,278 |
| Knee revision arthroplasty all components | CPT 27487 | $13,278 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,872.00 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,802.86 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,073.42 |
| ACL reconstruction | CPT 29888 | $6,802.86 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $35,408 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,272 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,485 |
| CABG single arterial graft | CPT 33533 | $2,025.00 |
| CABG 2 arterial grafts | CPT 33534 | $2,025.00 |
| CABG 3 arterial grafts | CPT 33535 | $2,025.00 |
| CABG 4+ arterial grafts | CPT 33536 | $2,025.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,331 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $10,728 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,079 |
| Open appendectomy | CPT 44950 | $3,363.87 |
| Laparoscopic appendectomy | CPT 44970 | $5,494.93 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $48,543 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $29,002 |
| Major joint replacement w MCC | MS-DRG 469 | $23,080 |
| Major joint replacement w/o MCC | MS-DRG 470 | $14,810 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,494.93 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,494.93 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,661 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,499 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,304 |
| Open umbilical hernia repair | CPT 49560 | $3,456.74 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,456.74 |
| Lap inguinal hernia repair | CPT 49650 | $5,494.93 |
| Lap incisional hernia repair | CPT 49652 | $5,494.93 |
| Total abdominal hysterectomy | CPT 58150 | $2,236.50 |
| Vaginal hysterectomy | CPT 58260 | $4,321.01 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,494.93 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $7,934.00 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,494.93 |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,146 |
| OR procedure for obesity w CC | MS-DRG 620 | $19,722 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $19,722 |
| Complex cataract surgery | CPT 66982 | $2,978.00 |
| Cataract surgery with lens implant | CPT 66984 | $2,978.00 |
| Intravitreal injection | CPT 67028 | $629.50 |
| Vitrectomy mechanical | CPT 67042 | $4,321.01 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,451.23 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $14,071 |
