| Psychoses | MS-DRG 885 | $11,123 |
| ED visit level 1 | CPT 99281 | $222.58 |
| ED visit level 2 | CPT 99282 | $290.91 |
| ED visit level 3 | CPT 99283 | $387.72 |
| ED visit level 4 | CPT 99284 | $559.52 |
| ED visit level 5 | CPT 99285 | $783.12 |
| Critical care, first hour | CPT 99291 | $942.76 |
| CT head without contrast | CPT 70450 | $739.89 |
| CT head with contrast | CPT 70460 | $882.58 |
| CT head with and without contrast | CPT 70470 | $989.52 |
| CT neck with contrast | CPT 70491 | $876.06 |
| MRI brain without contrast | CPT 70551 | $1,690.99 |
| MRI brain with contrast | CPT 70552 | $3,957.72 |
| MRI brain with and without contrast | CPT 70553 | $2,980.34 |
| Chest X-ray single view | CPT 71045 | $93.52 |
| Chest X-ray 2 views | CPT 71046 | $108.08 |
| Chest X-ray 3 views | CPT 71047 | $117.04 |
| CT chest without contrast | CPT 71250 | $876.06 |
| CT chest with contrast | CPT 71260 | $989.52 |
| CT chest with and without contrast | CPT 71270 | $1,118.48 |
| MRI chest without contrast | CPT 71550 | $3,125.20 |
| MRI chest with and without contrast | CPT 71552 | $5,666.96 |
| Lumbosacral spine X-ray | CPT 72100 | $119.03 |
| CT cervical spine without contrast | CPT 72125 | $876.06 |
| CT thoracic spine without contrast | CPT 72128 | $876.06 |
| CT lumbar spine without contrast | CPT 72131 | $876.06 |
| MRI cervical spine without contrast | CPT 72141 | $1,690.99 |
| MRI thoracic spine without contrast | CPT 72146 | $1,750.90 |
| MRI lumbar spine without contrast | CPT 72148 | $1,739.98 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,481.92 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,013.20 |
| MRI lumbar spine with contrast | CPT 72158 | $2,980.34 |
| CT pelvis without contrast | CPT 72192 | $876.06 |
| CT pelvis with contrast | CPT 72193 | $989.52 |
| Shoulder X-ray | CPT 73030 | $132.06 |
| Humerus X-ray | CPT 73060 | $114.66 |
| Hand X-ray 3 views | CPT 73130 | $119.66 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,810.35 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,734.08 |
| Knee X-ray 1-2 views | CPT 73560 | $111.60 |
| Ankle X-ray 3 views | CPT 73610 | $113.73 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,810.35 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,734.08 |
| CT abdomen without contrast | CPT 74150 | $873.76 |
| CT abdomen with contrast | CPT 74160 | $989.52 |
| CT abdomen with and without contrast | CPT 74170 | $1,118.48 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,618.16 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,846.87 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,148.55 |
| MRI abdomen without contrast | CPT 74181 | $1,690.99 |
| MRI abdomen with and without contrast | CPT 74183 | $2,541.84 |
| Abdominal ultrasound complete | CPT 76700 | $570.44 |
| Abdominal ultrasound limited | CPT 76705 | $287.86 |
| Retroperitoneal ultrasound complete | CPT 76770 | $700.96 |
| Obstetric ultrasound first trimester | CPT 76801 | $412.93 |
| Obstetric ultrasound after first trimester | CPT 76805 | $425.45 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,955.72 |
| Transvaginal ultrasound | CPT 76830 | $305.62 |
| Pelvic ultrasound complete | CPT 76856 | $305.62 |
| Scrotal ultrasound | CPT 76870 | $300.34 |
| Diagnostic mammography unilateral | CPT 77065 | $533.17 |
| Diagnostic mammography bilateral | CPT 77066 | $649.60 |
| Screening mammography bilateral | CPT 77067 | $222.30 |
| EKG tracing only | CPT 93005 | $86.84 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,626.04 |
| Stress echocardiogram | CPT 93350 | $901.60 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $15,852 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,316.09 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,861.87 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,476 |
| COPD w MCC | MS-DRG 190 | $9,223.57 |
| COPD w CC | MS-DRG 191 | $9,223.57 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,223.57 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,776.86 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,440.92 |
| AMI discharged alive w MCC | MS-DRG 280 | $9,223.57 |
| AMI discharged alive w CC | MS-DRG 281 | $9,223.57 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,223.57 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,376 |
| Heart failure & shock w CC | MS-DRG 292 | $7,101.42 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,970.27 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,223.57 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,223.57 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,223.57 |
| GI hemorrhage w CC | MS-DRG 378 | $8,093.17 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,455.23 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,578.79 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,514 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,445.66 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,803.96 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,336 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,413.98 |
| Basic metabolic panel (BMP) | CPT 80048 | $58.31 |
| Electrolyte panel | CPT 80051 | $50.71 |
| Comprehensive metabolic panel | CPT 80053 | $68.82 |
| Lipid panel | CPT 80061 | $68.82 |
| Renal function panel | CPT 80069 | $60.76 |
| Hepatic function panel | CPT 80076 | $70.00 |
| Urinalysis non-automated | CPT 81002 | $32.24 |
| Urinalysis automated | CPT 81003 | $19.84 |
| Glucose quantitative | CPT 82947 | $28.00 |
| Hemoglobin A1c | CPT 83036 | $65.63 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $92.15 |
| Complete blood count with automated differential | CPT 85025 | $48.38 |
| Complete blood count without differential | CPT 85027 | $65.52 |
| Urine culture bacterial | CPT 87086 | $53.24 |
| Urine culture identification | CPT 87088 | $53.65 |
| Tissue exam by pathologist level IV | CPT 88305 | $101.84 |
| Fetal non-stress test | CPT 59025 | $364.56 |
| Vaginal delivery only | CPT 59409 | $10,746 |
| Office visit, new patient, 15-29 min | CPT 99202 | $226.26 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $240.09 |
| Office visit, new patient, 45-59 min | CPT 99204 | $301.05 |
| Office visit, new patient, 60-74 min | CPT 99205 | $372.70 |
| Office visit, established patient, 5 min | CPT 99211 | $87.36 |
| Office visit, established patient, 10-19 min | CPT 99212 | $109.36 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $126.96 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $148.96 |
| Office visit, established patient, 40-54 min | CPT 99215 | $187.48 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,254.88 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,711.82 |
| Sigmoidoscopy diagnostic | CPT 45330 | $651.54 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,862.08 |
| Colonoscopy diagnostic | CPT 45378 | $1,550.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,711.82 |
| Colonoscopy with polyp removal | CPT 45385 | $1,633.70 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $9,223.57 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $9,223.57 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,264.96 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $35,322 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $18,760 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,381 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,447 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $10,993 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,365 |
| Laparoscopic appendectomy | CPT 44970 | $5,573.36 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $9,223.57 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $9,223.57 |
| Major joint replacement w MCC | MS-DRG 469 | $23,550 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,234 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,573.36 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,639 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,481 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $12,990 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,951.73 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $9,925.85 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,562.36 |
| OR procedure for obesity w MCC | MS-DRG 619 | $22,452 |
| OR procedure for obesity w CC | MS-DRG 620 | $12,759 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,067 |
| Complex cataract surgery | CPT 66982 | $2,326.61 |
| Cataract surgery with lens implant | CPT 66984 | $2,207.02 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,051 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,137 |
