| Psychoses | MS-DRG 885 | $13,724 |
| ED visit level 1 | CPT 99281 | $173.60 |
| ED visit level 2 | CPT 99282 | $253.44 |
| ED visit level 3 | CPT 99283 | $352.58 |
| ED visit level 4 | CPT 99284 | $456.88 |
| ED visit level 5 | CPT 99285 | $734.02 |
| Critical care, first hour | CPT 99291 | $1,679.79 |
| CT head without contrast | CPT 70450 | $1,146.46 |
| CT head with contrast | CPT 70460 | $1,789.17 |
| CT head with and without contrast | CPT 70470 | $1,989.78 |
| CT neck with contrast | CPT 70491 | $1,789.17 |
| MRI brain without contrast | CPT 70551 | $2,428.58 |
| MRI brain with contrast | CPT 70552 | $3,126.26 |
| MRI brain with and without contrast | CPT 70553 | $3,831.16 |
| Chest X-ray single view | CPT 71045 | $267.60 |
| Chest X-ray 2 views | CPT 71046 | $267.60 |
| Chest X-ray 3 views | CPT 71047 | $267.60 |
| CT chest without contrast | CPT 71250 | $1,154.01 |
| CT chest with contrast | CPT 71260 | $1,796.26 |
| CT chest with and without contrast | CPT 71270 | $1,997.66 |
| MRI chest without contrast | CPT 71550 | $2,428.58 |
| MRI chest with and without contrast | CPT 71552 | $3,831.16 |
| Lumbosacral spine X-ray | CPT 72100 | $267.60 |
| CT cervical spine without contrast | CPT 72125 | $1,154.01 |
| CT thoracic spine without contrast | CPT 72128 | $1,154.01 |
| CT lumbar spine without contrast | CPT 72131 | $1,154.01 |
| MRI cervical spine without contrast | CPT 72141 | $2,428.58 |
| MRI thoracic spine without contrast | CPT 72146 | $2,428.58 |
| MRI lumbar spine without contrast | CPT 72148 | $2,428.58 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,126.26 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,834.32 |
| MRI lumbar spine with contrast | CPT 72158 | $3,831.16 |
| CT pelvis without contrast | CPT 72192 | $1,154.01 |
| CT pelvis with contrast | CPT 72193 | $1,796.26 |
| Shoulder X-ray | CPT 73030 | $272.19 |
| Humerus X-ray | CPT 73060 | $272.19 |
| Hand X-ray 3 views | CPT 73130 | $272.19 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,460.53 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,881.57 |
| Knee X-ray 1-2 views | CPT 73560 | $272.19 |
| Ankle X-ray 3 views | CPT 73610 | $272.19 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,460.53 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,881.57 |
| CT abdomen without contrast | CPT 74150 | $1,154.01 |
| CT abdomen with contrast | CPT 74160 | $1,796.26 |
| CT abdomen with and without contrast | CPT 74170 | $1,997.66 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,422.12 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,470.16 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,470.16 |
| MRI abdomen without contrast | CPT 74181 | $2,428.58 |
| MRI abdomen with and without contrast | CPT 74183 | $3,831.16 |
| Abdominal ultrasound complete | CPT 76700 | $601.16 |
| Abdominal ultrasound limited | CPT 76705 | $1,007.95 |
| Retroperitoneal ultrasound complete | CPT 76770 | $859.95 |
| Obstetric ultrasound first trimester | CPT 76801 | $402.71 |
| Obstetric ultrasound after first trimester | CPT 76805 | $859.95 |
| Transvaginal ultrasound | CPT 76830 | $571.92 |
| Pelvic ultrasound complete | CPT 76856 | $508.44 |
| Scrotal ultrasound | CPT 76870 | $1,116.96 |
| EKG tracing only | CPT 93005 | $302.42 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,213.13 |
| Stress echocardiogram | CPT 93350 | $1,715.74 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $20,189 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,721 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,498.22 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,947 |
| COPD w MCC | MS-DRG 190 | $10,293 |
| COPD w CC | MS-DRG 191 | $10,293 |
| COPD w/o CC/MCC | MS-DRG 192 | $10,293 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,707.07 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,978.93 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,293 |
| AMI discharged alive w CC | MS-DRG 281 | $10,293 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,293 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,308 |
| Heart failure & shock w CC | MS-DRG 292 | $9,172.73 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,398.35 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,293 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,293 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $10,293 |
| GI hemorrhage w CC | MS-DRG 378 | $10,441 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,996.61 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,382.57 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,994 |
| Kidney/UTI w MCC | MS-DRG 689 | $12,140 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,660.34 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,541 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,844 |
| Basic metabolic panel (BMP) | CPT 80048 | $141.75 |
| Electrolyte panel | CPT 80051 | $75.62 |
| Comprehensive metabolic panel | CPT 80053 | $418.09 |
| Lipid panel | CPT 80061 | $312.16 |
| Renal function panel | CPT 80069 | $153.82 |
| Hepatic function panel | CPT 80076 | $217.15 |
| Urinalysis non-automated | CPT 81002 | $16.80 |
| Urinalysis automated | CPT 81003 | $33.55 |
| Glucose quantitative | CPT 82947 | $72.01 |
| Hemoglobin A1c | CPT 83036 | $98.04 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $162.64 |
| Complete blood count with automated differential | CPT 85025 | $40.16 |
| Complete blood count without differential | CPT 85027 | $44.84 |
| Urine culture bacterial | CPT 87086 | $47.74 |
| Tissue exam by pathologist level IV | CPT 88305 | $214.51 |
| Vaginal delivery only | CPT 59409 | $3,146.68 |
| C-section delivery only | CPT 59514 | $5,957.20 |
| Office visit, new patient, 15-29 min | CPT 99202 | $195.03 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $249.09 |
| Office visit, new patient, 45-59 min | CPT 99204 | $330.23 |
| Office visit, new patient, 60-74 min | CPT 99205 | $402.10 |
| Office visit, established patient, 5 min | CPT 99211 | $87.03 |
| Office visit, established patient, 10-19 min | CPT 99212 | $105.66 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $122.40 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $161.60 |
| Office visit, established patient, 40-54 min | CPT 99215 | $261.82 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,463.87 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,964.26 |
| Sigmoidoscopy diagnostic | CPT 45330 | $498.50 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,463.87 |
| Colonoscopy diagnostic | CPT 45378 | $990.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,964.26 |
| Colonoscopy with polyp removal | CPT 45385 | $3,459.14 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $10,293 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $10,293 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,312.83 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,892.29 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $44,651 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $23,843 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $17,084 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $17,167 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $14,084 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,398 |
| Laparoscopic appendectomy | CPT 44970 | $5,705.87 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $10,293 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $10,293 |
| Major joint replacement w MCC | MS-DRG 469 | $29,860 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,412 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,705.87 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,705.87 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,716 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,979 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $16,593 |
| OR procedure for obesity w MCC | MS-DRG 619 | $28,481 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,303 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $15,433 |
| Complex cataract surgery | CPT 66982 | $2,348.35 |
| Cataract surgery with lens implant | CPT 66984 | $2,315.74 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,900 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $20,175 |
| PCI single major coronary artery | CPT 92920 | $10,375 |
| PCI with drug-eluting stent | CPT 92928 | $15,758 |
| PCI bypass graft | CPT 92937 | $15,758 |
| Left heart catheterization | CPT 93452 | $4,538.16 |
| Coronary angiography with cath | CPT 93455 | $5,024.45 |
| Coronary angiography with bypass cath | CPT 93458 | $6,052.47 |
