| Psychoses | MS-DRG 885 | $10,777 |
| ED visit level 1 | CPT 99281 | $122.4 |
| ED visit level 2 | CPT 99282 | $230.22 |
| ED visit level 3 | CPT 99283 | $309.68 |
| ED visit level 4 | CPT 99284 | $446.57 |
| ED visit level 5 | CPT 99285 | $642.97 |
| Critical care, first hour | CPT 99291 | $867.6 |
| CT head without contrast | CPT 70450 | $661.04 |
| CT head with contrast | CPT 70460 | $785.33 |
| CT head with and without contrast | CPT 70470 | $957.15 |
| CT neck with contrast | CPT 70491 | $824.61 |
| MRI brain without contrast | CPT 70551 | $1,354.22 |
| MRI brain with contrast | CPT 70552 | $1,625.79 |
| MRI brain with and without contrast | CPT 70553 | $2,869.54 |
| Chest X-ray single view | CPT 71045 | $90.66 |
| Chest X-ray 2 views | CPT 71046 | $90.66 |
| Chest X-ray 3 views | CPT 71047 | $90.66 |
| CT chest without contrast | CPT 71250 | $815.23 |
| CT chest with contrast | CPT 71260 | $951.63 |
| CT chest with and without contrast | CPT 71270 | $1,162.93 |
| MRI chest without contrast | CPT 71550 | $1,373 |
| MRI chest with contrast | CPT 71551 | $1,412.35 |
| MRI chest with and without contrast | CPT 71552 | $2,278.92 |
| Lumbosacral spine X-ray | CPT 72100 | $111.52 |
| CT cervical spine without contrast | CPT 72125 | $815.23 |
| CT thoracic spine without contrast | CPT 72128 | $815.23 |
| CT lumbar spine without contrast | CPT 72131 | $815.23 |
| MRI cervical spine without contrast | CPT 72141 | $1,373 |
| MRI thoracic spine without contrast | CPT 72146 | $1,497.28 |
| MRI lumbar spine without contrast | CPT 72148 | $1,478.45 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,625.79 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,898.99 |
| MRI lumbar spine with contrast | CPT 72158 | $2,869.54 |
| CT pelvis without contrast | CPT 72192 | $803.57 |
| CT pelvis with contrast | CPT 72193 | $914.04 |
| Shoulder X-ray | CPT 73030 | $133.09 |
| Humerus X-ray | CPT 73060 | $133.16 |
| Hand X-ray 3 views | CPT 73130 | $124.93 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,805.94 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,203.32 |
| Knee X-ray 1-2 views | CPT 73560 | $121.86 |
| Ankle X-ray 3 views | CPT 73610 | $124.93 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,805.94 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,203.32 |
| CT abdomen without contrast | CPT 74150 | $793.5 |
| CT abdomen with contrast | CPT 74160 | $931.86 |
| CT abdomen with and without contrast | CPT 74170 | $1,129.95 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,066.48 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,233.18 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,486.28 |
| MRI abdomen without contrast | CPT 74181 | $1,373 |
| MRI abdomen with and without contrast | CPT 74183 | $2,293.29 |
| Abdominal ultrasound complete | CPT 76700 | $343.34 |
| Abdominal ultrasound limited | CPT 76705 | $254.92 |
| Retroperitoneal ultrasound complete | CPT 76770 | $332 |
| Obstetric ultrasound first trimester | CPT 76801 | $230.52 |
| Obstetric ultrasound after first trimester | CPT 76805 | $389.05 |
| Transvaginal ultrasound | CPT 76830 | $279.05 |
| Pelvic ultrasound complete | CPT 76856 | $282.47 |
| Scrotal ultrasound | CPT 76870 | $270.61 |
| Diagnostic mammography unilateral | CPT 77065 | $284.8 |
| EKG tracing only | CPT 93005 | $62.36 |
| Transthoracic echocardiogram complete | CPT 93306 | $953.17 |
| Transthoracic echocardiogram | CPT 93307 | $655.62 |
| Stress echocardiogram | CPT 93350 | $591.94 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $15,659 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $7,866.89 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,378.08 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,168 |
| COPD w MCC | MS-DRG 190 | $9,159.77 |
| COPD w CC | MS-DRG 191 | $31,581 |
| COPD w/o CC/MCC | MS-DRG 192 | $15,684 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,332.86 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,938.82 |
| AMI discharged alive w MCC | MS-DRG 280 | $9,172.94 |
| AMI discharged alive w CC | MS-DRG 281 | $7,745.74 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,280.19 |
| Heart failure & shock w MCC | MS-DRG 291 | $9,996.55 |
| Heart failure & shock w CC | MS-DRG 292 | $6,671.56 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,447.71 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,802 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,916.16 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $10,627 |
| GI hemorrhage w CC | MS-DRG 378 | $7,636.4 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,953.77 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,126.2 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,207 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,034.89 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,361.16 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,126 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $7,968.11 |
| Basic metabolic panel (BMP) | CPT 80048 | $118.3 |
| Electrolyte panel | CPT 80051 | $31.58 |
| Comprehensive metabolic panel | CPT 80053 | $164.5 |
| Lipid panel | CPT 80061 | $47.74 |
| Renal function panel | CPT 80069 | $40.41 |
| Hepatic function panel | CPT 80076 | $117.25 |
| Urinalysis non-automated | CPT 81002 | $12.19 |
| Urinalysis automated | CPT 81003 | $10.72 |
| Glucose quantitative | CPT 82947 | $13.33 |
| Hemoglobin A1c | CPT 83036 | $36.11 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $56.93 |
| Complete blood count with automated differential | CPT 85025 | $26.33 |
| Complete blood count without differential | CPT 85027 | $21.93 |
| Urine culture bacterial | CPT 87086 | $26.98 |
| Urine culture identification | CPT 87088 | $27.41 |
| Tissue exam by pathologist level IV | CPT 88305 | $477.25 |
| Vaginal delivery only | CPT 59409 | $4,392.36 |
| Vaginal delivery with postpartum | CPT 59410 | $3,822.7 |
| C-section with postpartum | CPT 59515 | $4,554.9 |
| Office visit, new patient, 15-29 min | CPT 99202 | $131.41 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $169.32 |
| Office visit, new patient, 45-59 min | CPT 99204 | $233.31 |
| Office visit, new patient, 60-74 min | CPT 99205 | $335.1 |
| Office visit, established patient, 5 min | CPT 99211 | $72.4 |
| Office visit, established patient, 10-19 min | CPT 99212 | $83.6 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $110.63 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $159.62 |
| Office visit, established patient, 40-54 min | CPT 99215 | $245.72 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,074.06 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,254.6 |
| Sigmoidoscopy diagnostic | CPT 45330 | $847.45 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,013.54 |
| Colonoscopy diagnostic | CPT 45378 | $1,139.3 |
| Colonoscopy with biopsy | CPT 45380 | $1,254.6 |
| Colonoscopy with polyp removal | CPT 45385 | $1,640.37 |
| Total shoulder arthroplasty | CPT 23472 | $16,293 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $8,454.85 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $8,456.65 |
| Total hip replacement | CPT 27130 | $12,267 |
| Total knee replacement | CPT 27447 | $12,267 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,462.16 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,810.69 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $35,791 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $18,666 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,104 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,172 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $10,635 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,530 |
| Open appendectomy | CPT 44950 | $5,948.85 |
| Laparoscopic appendectomy | CPT 44970 | $5,562.36 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $15,644 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $11,144 |
| Major joint replacement w MCC | MS-DRG 469 | $23,835 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,158 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,562.36 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,885 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,459 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $12,817 |
| Umbilical hernia repair age 5+ | CPT 49585 | $4,148 |
| Lap inguinal hernia repair | CPT 49650 | $5,562.36 |
| Total abdominal hysterectomy | CPT 58150 | $3,725.73 |
| OR procedure for obesity w MCC | MS-DRG 619 | $22,483 |
| OR procedure for obesity w CC | MS-DRG 620 | $12,461 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $11,745 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,660.92 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $15,956 |
| PCI single major coronary artery | CPT 92920 | $7,333.66 |
| PCI with drug-eluting stent | CPT 92928 | $13,002 |
| Left heart catheterization | CPT 93452 | $4,969.8 |
| Coronary angiography with cath | CPT 93455 | $5,759.92 |
| Coronary angiography with bypass cath | CPT 93458 | $7,236.31 |
