| Psychoses | MS-DRG 885 | $16,812 |
| Psychiatric diagnostic evaluation | CPT 90791 | $326.5 |
| ED visit level 1 | CPT 99281 | $200 |
| ED visit level 2 | CPT 99282 | $327 |
| ED visit level 3 | CPT 99283 | $545 |
| ED visit level 4 | CPT 99284 | $855.5 |
| ED visit level 5 | CPT 99285 | $2,580.86 |
| Critical care, first hour | CPT 99291 | $1,883 |
| CT head without contrast | CPT 70450 | $810.03 |
| CT head with contrast | CPT 70460 | $959 |
| CT head with and without contrast | CPT 70470 | $1,044 |
| CT neck with contrast | CPT 70491 | $1,109 |
| MRI brain without contrast | CPT 70551 | $1,340.67 |
| MRI brain with contrast | CPT 70552 | $1,418.5 |
| MRI brain with and without contrast | CPT 70553 | $1,503.5 |
| Chest X-ray single view | CPT 71045 | $187.5 |
| Chest X-ray 2 views | CPT 71046 | $234.5 |
| Chest X-ray 3 views | CPT 71047 | $320.5 |
| CT chest without contrast | CPT 71250 | $974 |
| CT chest with contrast | CPT 71260 | $1,120 |
| CT chest with and without contrast | CPT 71270 | $1,172.5 |
| MRI chest without contrast | CPT 71550 | $1,171.33 |
| MRI chest with contrast | CPT 71551 | $1,350.25 |
| MRI chest with and without contrast | CPT 71552 | $1,844.5 |
| Lumbosacral spine X-ray | CPT 72100 | $281.5 |
| CT cervical spine without contrast | CPT 72125 | $1,005.5 |
| CT thoracic spine without contrast | CPT 72128 | $938.5 |
| CT lumbar spine without contrast | CPT 72131 | $1,112 |
| MRI cervical spine without contrast | CPT 72141 | $1,406.5 |
| MRI thoracic spine without contrast | CPT 72146 | $1,452.5 |
| MRI lumbar spine without contrast | CPT 72148 | $1,452.5 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,565 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,660.5 |
| MRI lumbar spine with contrast | CPT 72158 | $1,660.5 |
| CT pelvis without contrast | CPT 72192 | $896.5 |
| CT pelvis with contrast | CPT 72193 | $1,096.5 |
| Shoulder X-ray | CPT 73030 | $295.5 |
| Humerus X-ray | CPT 73060 | $233 |
| Hand X-ray 3 views | CPT 73130 | $276.5 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,363.5 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,685 |
| Knee X-ray 1-2 views | CPT 73560 | $181.5 |
| Ankle X-ray 3 views | CPT 73610 | $254.5 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,685 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,685 |
| CT abdomen without contrast | CPT 74150 | $1,104 |
| CT abdomen with contrast | CPT 74160 | $1,258 |
| CT abdomen with and without contrast | CPT 74170 | $1,313.5 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,519.49 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,548.78 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,599.1 |
| MRI abdomen without contrast | CPT 74181 | $1,465 |
| MRI abdomen with and without contrast | CPT 74183 | $1,685.5 |
| Abdominal ultrasound complete | CPT 76700 | $718 |
| Abdominal ultrasound limited | CPT 76705 | $482.5 |
| Retroperitoneal ultrasound complete | CPT 76770 | $623.5 |
| Obstetric ultrasound first trimester | CPT 76801 | $514 |
| Obstetric ultrasound after first trimester | CPT 76805 | $556 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $587 |
| Transvaginal ultrasound | CPT 76830 | $562.5 |
| Pelvic ultrasound complete | CPT 76856 | $589.5 |
| Scrotal ultrasound | CPT 76870 | $471.5 |
| Diagnostic mammography unilateral | CPT 77065 | $309.12 |
| Diagnostic mammography bilateral | CPT 77066 | $403.2 |
| Screening mammography bilateral | CPT 77067 | $313.44 |
| EKG tracing only | CPT 93005 | $187.5 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,363 |
| Transthoracic echocardiogram | CPT 93307 | $819.5 |
| Stress echocardiogram | CPT 93350 | $1,249.5 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $23,451 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $12,313 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $8,549.09 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $19,182 |
| COPD w MCC | MS-DRG 190 | $13,529 |
| COPD w CC | MS-DRG 191 | $10,506 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,078.28 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,058 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,797.66 |
| AMI discharged alive w MCC | MS-DRG 280 | $19,467 |
| AMI discharged alive w CC | MS-DRG 281 | $11,224 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,970.63 |
| Heart failure & shock w MCC | MS-DRG 291 | $15,611 |
| Heart failure & shock w CC | MS-DRG 292 | $10,530 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,949.99 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $14,478 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,133.28 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,073.69 |
| GI hemorrhage w CC | MS-DRG 378 | $11,958 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,958.03 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,602.95 |
| Fractures of femur w/o MCC | MS-DRG 533 | $18,132 |
| Kidney/UTI w MCC | MS-DRG 689 | $14,070 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,858.39 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $23,140 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $12,475 |
| Basic metabolic panel (BMP) | CPT 80048 | $77.42 |
| General health panel | CPT 80050 | $58.25 |
| Electrolyte panel | CPT 80051 | $75.46 |
| Comprehensive metabolic panel | CPT 80053 | $124.46 |
| Lipid panel | CPT 80061 | $33.16 |
| Renal function panel | CPT 80069 | $118.09 |
| Hepatic function panel | CPT 80076 | $89.18 |
| Urinalysis non-automated | CPT 81002 | $5.56 |
| Urinalysis automated | CPT 81003 | $41.5 |
| Glucose quantitative | CPT 82947 | $37.18 |
| Hemoglobin A1c | CPT 83036 | $72.03 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $87.5 |
| Complete blood count with automated differential | CPT 85025 | $65.66 |
| Complete blood count without differential | CPT 85027 | $58 |
| Urine culture bacterial | CPT 87086 | $79.38 |
| Urine culture identification | CPT 87088 | $14.48 |
| Tissue exam by pathologist level IV | CPT 88305 | $238.29 |
| Fetal non-stress test | CPT 59025 | $311.1 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,372.22 |
| Vaginal delivery only | CPT 59409 | $3,633 |
| Vaginal delivery with postpartum | CPT 59410 | $2,459.71 |
| Routine obstetric care with C-section | CPT 59510 | $2,372.22 |
| C-section delivery only | CPT 59514 | $3,414 |
| C-section with postpartum | CPT 59515 | $4,078.35 |
| Office visit, established patient, 5 min | CPT 99211 | $98 |
| Office visit, established patient, 10-19 min | CPT 99212 | $102.2 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $119.47 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $119.47 |
| Office visit, established patient, 40-54 min | CPT 99215 | $140.4 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,612 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,587.9 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,147.46 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,263.68 |
| Colonoscopy diagnostic | CPT 45378 | $1,676.85 |
| Colonoscopy with biopsy | CPT 45380 | $1,785.8 |
| Colonoscopy with polyp removal | CPT 45385 | $1,759.35 |
| Total shoulder arthroplasty | CPT 23472 | $7,084.58 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $55,641 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $51,029 |
| Hip hemiarthroplasty | CPT 27125 | $8,242 |
| Total hip replacement | CPT 27130 | $10,993 |
| Total knee replacement | CPT 27447 | $21,902 |
| Knee revision arthroplasty single component | CPT 27486 | $10,993 |
| Knee revision arthroplasty all components | CPT 27487 | $10,993 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,296 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,358.97 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $4,070.05 |
| ACL reconstruction | CPT 29888 | $5,584.78 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $53,264 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $27,741 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $19,577 |
| CABG single arterial graft | CPT 33533 | $2,020 |
| CABG 2 arterial grafts | CPT 33534 | $2,020 |
| CABG 3 arterial grafts | CPT 33535 | $2,020 |
| CABG 4+ arterial grafts | CPT 33536 | $2,020 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $19,662 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,758 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $41,095 |
| Open appendectomy | CPT 44950 | $4,947.09 |
| Laparoscopic appendectomy | CPT 44970 | $4,084.98 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $63,366 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $54,801 |
| Major joint replacement w MCC | MS-DRG 469 | $38,107 |
| Major joint replacement w/o MCC | MS-DRG 470 | $22,263 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,784.48 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,784.48 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $34,354 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $24,450 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,837 |
| Open umbilical hernia repair | CPT 49560 | $2,911.46 |
| Umbilical hernia repair age 5+ | CPT 49585 | $2,911.46 |
| Lap inguinal hernia repair | CPT 49650 | $4,298.25 |
| Lap incisional hernia repair | CPT 49652 | $6,014.95 |
| Total abdominal hysterectomy | CPT 58150 | $5,776 |
| Vaginal hysterectomy | CPT 58260 | $5,776 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,692.61 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $8,037.09 |
| Lap salpingo-oophorectomy | CPT 58661 | $4,951.44 |
| OR procedure for obesity w MCC | MS-DRG 619 | $31,896 |
| OR procedure for obesity w CC | MS-DRG 620 | $19,100 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $17,511 |
| Complex cataract surgery | CPT 66982 | $3,895.68 |
| Cataract surgery with lens implant | CPT 66984 | $3,895.68 |
| Intravitreal injection | CPT 67028 | $1,415.22 |
| Vitrectomy mechanical | CPT 67042 | $5,776 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,396 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $23,048 |
| PCI single major coronary artery | CPT 92920 | $8,700 |
| PCI with drug-eluting stent | CPT 92928 | $8,700 |
| PCI bypass graft | CPT 92937 | $8,700 |
| Left heart catheterization | CPT 93452 | $6,418 |
| Coronary angiography with cath | CPT 93455 | $8,753.87 |
| Coronary angiography with bypass cath | CPT 93458 | $6,418 |
