| Psychoses | MS-DRG 885 | $12,379 |
| ED visit level 1 | CPT 99281 | $151.24 |
| ED visit level 2 | CPT 99282 | $177.43 |
| ED visit level 3 | CPT 99283 | $287.74 |
| ED visit level 4 | CPT 99284 | $534.96 |
| ED visit level 5 | CPT 99285 | $1,390.47 |
| Critical care, first hour | CPT 99291 | $1,189.72 |
| CT head without contrast | CPT 70450 | $812 |
| CT head with contrast | CPT 70460 | $1,257.03 |
| CT head with and without contrast | CPT 70470 | $1,413.72 |
| CT neck with contrast | CPT 70491 | $1,270.64 |
| MRI brain without contrast | CPT 70551 | $1,718.64 |
| MRI brain with contrast | CPT 70552 | $2,213.12 |
| MRI brain with and without contrast | CPT 70553 | $2,750.26 |
| Chest X-ray single view | CPT 71045 | $180.57 |
| Chest X-ray 2 views | CPT 71046 | $180.57 |
| Chest X-ray 3 views | CPT 71047 | $180.57 |
| CT chest without contrast | CPT 71250 | $832.3 |
| CT chest with contrast | CPT 71260 | $1,270.64 |
| CT chest with and without contrast | CPT 71270 | $1,413.72 |
| MRI chest without contrast | CPT 71550 | $1,718.64 |
| MRI chest with contrast | CPT 71551 | $1,577.89 |
| MRI chest with and without contrast | CPT 71552 | $2,750.26 |
| Lumbosacral spine X-ray | CPT 72100 | $186.98 |
| CT cervical spine without contrast | CPT 72125 | $832.3 |
| CT thoracic spine without contrast | CPT 72128 | $832.3 |
| CT lumbar spine without contrast | CPT 72131 | $832.3 |
| MRI cervical spine without contrast | CPT 72141 | $1,718.64 |
| MRI thoracic spine without contrast | CPT 72146 | $1,743.19 |
| MRI lumbar spine without contrast | CPT 72148 | $1,743.19 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,213.12 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,750.26 |
| MRI lumbar spine with contrast | CPT 72158 | $2,750.26 |
| CT pelvis without contrast | CPT 72192 | $832.3 |
| CT pelvis with contrast | CPT 72193 | $1,270.64 |
| Shoulder X-ray | CPT 73030 | $193.73 |
| Humerus X-ray | CPT 73060 | $193.73 |
| Hand X-ray 3 views | CPT 73130 | $193.73 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,780.02 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,918.67 |
| Knee X-ray 1-2 views | CPT 73560 | $193.61 |
| Ankle X-ray 3 views | CPT 73610 | $193.73 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,780.02 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,918.67 |
| CT abdomen without contrast | CPT 74150 | $832.3 |
| CT abdomen with contrast | CPT 74160 | $1,270.64 |
| CT abdomen with and without contrast | CPT 74170 | $1,413.72 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,715.28 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,430.12 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,456.44 |
| MRI abdomen without contrast | CPT 74181 | $1,718.64 |
| MRI abdomen with and without contrast | CPT 74183 | $2,750.26 |
| Abdominal ultrasound complete | CPT 76700 | $1,031.48 |
| Abdominal ultrasound limited | CPT 76705 | $494.17 |
| Retroperitoneal ultrasound complete | CPT 76770 | $401.8 |
| Obstetric ultrasound first trimester | CPT 76801 | $213.15 |
| Obstetric ultrasound after first trimester | CPT 76805 | $816.6 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $779.21 |
| Transvaginal ultrasound | CPT 76830 | $743.92 |
| Pelvic ultrasound complete | CPT 76856 | $744.99 |
| Scrotal ultrasound | CPT 76870 | $494.17 |
| Diagnostic mammography unilateral | CPT 77065 | $203.87 |
| Diagnostic mammography bilateral | CPT 77066 | $267.71 |
| Screening mammography bilateral | CPT 77067 | $136.9 |
| EKG tracing only | CPT 93005 | $92.52 |
| Transthoracic echocardiogram complete | CPT 93306 | $935.25 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $20,714 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,407 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,049.66 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $16,097 |
| COPD w MCC | MS-DRG 190 | $11,410 |
| COPD w CC | MS-DRG 191 | $8,683.32 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,612.92 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,301.17 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,473.86 |
| AMI discharged alive w MCC | MS-DRG 280 | $16,523 |
| AMI discharged alive w CC | MS-DRG 281 | $9,467.19 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,448.29 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,224 |
| Heart failure & shock w CC | MS-DRG 292 | $8,745.12 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,830.08 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,402 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,578.08 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,831.11 |
| GI hemorrhage w CC | MS-DRG 378 | $10,102 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,493.44 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,030.27 |
| Fractures of femur w/o MCC | MS-DRG 533 | $16,148 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,952 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,338.25 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $20,009 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,541 |
| Basic metabolic panel (BMP) | CPT 80048 | $46.5 |
| Electrolyte panel | CPT 80051 | $42.04 |
| Comprehensive metabolic panel | CPT 80053 | $48.43 |
| Lipid panel | CPT 80061 | $126.75 |
| Renal function panel | CPT 80069 | $54.35 |
| Hepatic function panel | CPT 80076 | $99.45 |
| Urinalysis non-automated | CPT 81002 | $32.51 |
| Urinalysis automated | CPT 81003 | $19.04 |
| Glucose quantitative | CPT 82947 | $31.58 |
| Hemoglobin A1c | CPT 83036 | $46.5 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $95.2 |
| Complete blood count with automated differential | CPT 85025 | $43.64 |
| Complete blood count without differential | CPT 85027 | $26.98 |
| Urine culture bacterial | CPT 87086 | $77.31 |
| Urine culture identification | CPT 87088 | $33.58 |
| Tissue exam by pathologist level IV | CPT 88305 | $337.59 |
| Vaginal delivery only | CPT 59409 | $4,156.06 |
| Office visit, new patient, 15-29 min | CPT 99202 | $90.06 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $140.6 |
| Office visit, new patient, 45-59 min | CPT 99204 | $219.29 |
| Office visit, new patient, 60-74 min | CPT 99205 | $260.91 |
| Office visit, established patient, 5 min | CPT 99211 | $63.91 |
| Office visit, established patient, 10-19 min | CPT 99212 | $80.57 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $103.8 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $125.62 |
| Office visit, established patient, 40-54 min | CPT 99215 | $145.99 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,988.91 |
| Sigmoidoscopy diagnostic | CPT 45330 | $398.8 |
| Sigmoidoscopy with biopsy | CPT 45331 | $947.44 |
| Colonoscopy diagnostic | CPT 45378 | $950 |
| Colonoscopy with biopsy | CPT 45380 | $2,271.64 |
| Colonoscopy with polyp removal | CPT 45385 | $2,116.15 |
| Total shoulder arthroplasty | CPT 23472 | $10,244 |
| Total hip replacement | CPT 27130 | $10,591 |
| Total knee replacement | CPT 27447 | $10,591 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,453.84 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $4,939.05 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,494.05 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $47,346 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $24,692 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $17,335 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $17,424 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $14,068 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $35,095 |
| Laparoscopic appendectomy | CPT 44970 | $4,911.06 |
| Major joint replacement w MCC | MS-DRG 469 | $31,243 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,869 |
| Laparoscopic cholecystectomy | CPT 47562 | $4,911.06 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $4,911.06 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $29,998 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $21,574 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $16,800 |
| OR procedure for obesity w MCC | MS-DRG 619 | $29,742 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,484 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $15,537 |
| Complex cataract surgery | CPT 66982 | $2,348.35 |
| Cataract surgery with lens implant | CPT 66984 | $2,331.1 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,780 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,144 |
| Coronary angiography with bypass cath | CPT 93458 | $8,220.54 |
