| Psychoses | MS-DRG 885 | $13,500 |
| ED visit level 1 | CPT 99281 | $220 |
| ED visit level 2 | CPT 99282 | $304.1 |
| ED visit level 3 | CPT 99283 | $396.6 |
| ED visit level 4 | CPT 99284 | $788.53 |
| ED visit level 5 | CPT 99285 | $1,028.57 |
| Critical care, first hour | CPT 99291 | $1,154.4 |
| CT head without contrast | CPT 70450 | $778.1 |
| CT head with contrast | CPT 70460 | $781.8 |
| CT head with and without contrast | CPT 70470 | $899.55 |
| CT neck with contrast | CPT 70491 | $693 |
| MRI brain without contrast | CPT 70551 | $1,478 |
| MRI brain with contrast | CPT 70552 | $1,479.38 |
| MRI brain with and without contrast | CPT 70553 | $2,610.88 |
| Chest X-ray single view | CPT 71045 | $121.95 |
| Chest X-ray 2 views | CPT 71046 | $133.2 |
| Chest X-ray 3 views | CPT 71047 | $155.4 |
| CT chest without contrast | CPT 71250 | $820.95 |
| CT chest with contrast | CPT 71260 | $820.95 |
| CT chest with and without contrast | CPT 71270 | $1,026 |
| MRI chest without contrast | CPT 71550 | $920.43 |
| MRI chest with contrast | CPT 71551 | $1,357.92 |
| MRI chest with and without contrast | CPT 71552 | $1,207.5 |
| Lumbosacral spine X-ray | CPT 72100 | $182.5 |
| CT cervical spine without contrast | CPT 72125 | $976.03 |
| CT thoracic spine without contrast | CPT 72128 | $701.1 |
| CT lumbar spine without contrast | CPT 72131 | $701.1 |
| MRI cervical spine without contrast | CPT 72141 | $753.9 |
| MRI thoracic spine without contrast | CPT 72146 | $821.4 |
| MRI lumbar spine without contrast | CPT 72148 | $811.5 |
| MRI lumbar spine with and without contrast | CPT 72149 | $773.4 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,281.3 |
| MRI lumbar spine with contrast | CPT 72158 | $1,268.1 |
| CT pelvis without contrast | CPT 72192 | $709.5 |
| CT pelvis with contrast | CPT 72193 | $786.07 |
| Shoulder X-ray | CPT 73030 | $170.7 |
| Humerus X-ray | CPT 73060 | $118.5 |
| Hand X-ray 3 views | CPT 73130 | $125.1 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,124.97 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,328.25 |
| Knee X-ray 1-2 views | CPT 73560 | $126.9 |
| Ankle X-ray 3 views | CPT 73610 | $162.6 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,124.97 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,328.25 |
| CT abdomen without contrast | CPT 74150 | $949.58 |
| CT abdomen with contrast | CPT 74160 | $1,026 |
| CT abdomen with and without contrast | CPT 74170 | $1,318.2 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,433.74 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,736.4 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,298.03 |
| MRI abdomen without contrast | CPT 74181 | $1,082.16 |
| MRI abdomen with and without contrast | CPT 74183 | $1,286.01 |
| Abdominal ultrasound complete | CPT 76700 | $276.9 |
| Abdominal ultrasound limited | CPT 76705 | $219.23 |
| Retroperitoneal ultrasound complete | CPT 76770 | $221.1 |
| Obstetric ultrasound first trimester | CPT 76801 | $278.17 |
| Obstetric ultrasound after first trimester | CPT 76805 | $327.93 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $393.59 |
| Transvaginal ultrasound | CPT 76830 | $226.31 |
| Pelvic ultrasound complete | CPT 76856 | $276 |
| Scrotal ultrasound | CPT 76870 | $276 |
| Diagnostic mammography unilateral | CPT 77065 | $239.4 |
| Diagnostic mammography bilateral | CPT 77066 | $306 |
| Screening mammography bilateral | CPT 77067 | $136.8 |
| EKG tracing only | CPT 93005 | $80.34 |
| Transthoracic echocardiogram complete | CPT 93306 | $694.04 |
| Transthoracic echocardiogram | CPT 93307 | $393.4 |
| Stress echocardiogram | CPT 93350 | $522.91 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $19,473 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $9,918.9 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,778.64 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,204 |
| COPD w MCC | MS-DRG 190 | $9,495.41 |
| COPD w CC | MS-DRG 191 | $9,495.41 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,495.41 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,924.92 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,251.26 |
| AMI discharged alive w MCC | MS-DRG 280 | $9,495.41 |
| AMI discharged alive w CC | MS-DRG 281 | $9,495.41 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,495.41 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,549 |
| Heart failure & shock w CC | MS-DRG 292 | $8,335.3 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,661.63 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,495.41 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,495.41 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,495.41 |
| GI hemorrhage w CC | MS-DRG 378 | $9,628.3 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,269.18 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,676.77 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,252 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,373 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,958.87 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,820 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,047 |
| Basic metabolic panel (BMP) | CPT 80048 | $88.28 |
| Electrolyte panel | CPT 80051 | $32.65 |
| Comprehensive metabolic panel | CPT 80053 | $98.88 |
| Lipid panel | CPT 80061 | $58.72 |
| Renal function panel | CPT 80069 | $53.21 |
| Hepatic function panel | CPT 80076 | $46.47 |
| Urinalysis non-automated | CPT 81002 | $10.4 |
| Urinalysis automated | CPT 81003 | $10.59 |
| Glucose quantitative | CPT 82947 | $4.17 |
| Hemoglobin A1c | CPT 83036 | $10.3 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $81.24 |
| Complete blood count with automated differential | CPT 85025 | $49.47 |
| Complete blood count without differential | CPT 85027 | $38.25 |
| Urine culture bacterial | CPT 87086 | $20.15 |
| Urine culture identification | CPT 87088 | $20.42 |
| Tissue exam by pathologist level IV | CPT 88305 | $102.15 |
| Fetal non-stress test | CPT 59025 | $366.6 |
| Vaginal delivery only | CPT 59409 | $4,657.8 |
| C-section delivery only | CPT 59514 | $6,582 |
| Office visit, new patient, 15-29 min | CPT 99202 | $120 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $154.4 |
| Office visit, new patient, 45-59 min | CPT 99204 | $198 |
| Office visit, new patient, 60-74 min | CPT 99205 | $230.51 |
| Office visit, established patient, 5 min | CPT 99211 | $63.91 |
| Office visit, established patient, 10-19 min | CPT 99212 | $84.32 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $104.4 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $118.8 |
| Office visit, established patient, 40-54 min | CPT 99215 | $137.2 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | $672.98 |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | $1,028.66 |
| Colonoscopy with biopsy | CPT 45380 | — |
| Colonoscopy with polyp removal | CPT 45385 | — |
| Total shoulder arthroplasty | CPT 23472 | $20,656 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $9,495.41 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $9,495.41 |
| Total hip replacement | CPT 27130 | $14,582 |
| Total knee replacement | CPT 27447 | $14,582 |
| Knee revision arthroplasty single component | CPT 27486 | $4,632.7 |
| Knee revision arthroplasty all components | CPT 27487 | $5,035.44 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,529.08 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $8,023.89 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,570.11 |
| ACL reconstruction | CPT 29888 | $8,023.89 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $44,091 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $23,150 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,349 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,432 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,329 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $32,766 |
| Laparoscopic appendectomy | CPT 44970 | $6,612.25 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $9,495.41 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $9,495.41 |
| Major joint replacement w MCC | MS-DRG 469 | $29,206 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,691 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,612.25 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,612.25 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,055 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,268 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,855 |
| Lap inguinal hernia repair | CPT 49650 | $6,553.19 |
| Total abdominal hysterectomy | CPT 58150 | $4,042 |
| Vaginal hysterectomy | CPT 58260 | $5,703.25 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,869.04 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $11,694 |
| Lap salpingo-oophorectomy | CPT 58661 | — |
| OR procedure for obesity w MCC | MS-DRG 619 | $27,817 |
| OR procedure for obesity w CC | MS-DRG 620 | $15,562 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,687 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,138 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $19,835 |
| PCI single major coronary artery | CPT 92920 | $11,772 |
| PCI with drug-eluting stent | CPT 92928 | $17,879 |
| PCI bypass graft | CPT 92937 | $17,879 |
| Left heart catheterization | CPT 93452 | $7,050.05 |
| Coronary angiography with cath | CPT 93455 | $6,125.1 |
| Coronary angiography with bypass cath | CPT 93458 | $9,880.67 |
