| Psychoses | MS-DRG 885 | $11,354 |
| ED visit level 1 | CPT 99281 | $96 |
| ED visit level 2 | CPT 99282 | $157.2 |
| ED visit level 3 | CPT 99283 | $264.53 |
| ED visit level 4 | CPT 99284 | $380 |
| ED visit level 5 | CPT 99285 | $737.26 |
| Critical care, first hour | CPT 99291 | $846.55 |
| CT head without contrast | CPT 70450 | $919.36 |
| CT head with contrast | CPT 70460 | $1,111 |
| CT head with and without contrast | CPT 70470 | $1,353.7 |
| CT neck with contrast | CPT 70491 | $1,164.72 |
| MRI brain without contrast | CPT 70551 | $1,589.55 |
| MRI brain with contrast | CPT 70552 | $1,678.75 |
| MRI brain with and without contrast | CPT 70553 | $2,341.17 |
| Chest X-ray single view | CPT 71045 | $194.82 |
| Chest X-ray 2 views | CPT 71046 | $271.22 |
| Chest X-ray 3 views | CPT 71047 | $84.4 |
| CT chest without contrast | CPT 71250 | $1,152.53 |
| CT chest with contrast | CPT 71260 | $1,347.22 |
| CT chest with and without contrast | CPT 71270 | $1,642.11 |
| MRI chest without contrast | CPT 71550 | $2,189.99 |
| MRI chest with and without contrast | CPT 71552 | $3,267.12 |
| Lumbosacral spine X-ray | CPT 72100 | $274.66 |
| CT cervical spine without contrast | CPT 72125 | $1,152.53 |
| CT thoracic spine without contrast | CPT 72128 | $1,152.53 |
| CT lumbar spine without contrast | CPT 72131 | $1,152.53 |
| MRI cervical spine without contrast | CPT 72141 | $3,086.86 |
| MRI thoracic spine without contrast | CPT 72146 | $3,086.86 |
| MRI lumbar spine without contrast | CPT 72148 | $3,086.86 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,151.67 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,341.17 |
| MRI lumbar spine with contrast | CPT 72158 | $2,341.17 |
| CT pelvis without contrast | CPT 72192 | $1,149.56 |
| CT pelvis with contrast | CPT 72193 | $1,306.85 |
| Shoulder X-ray | CPT 73030 | $289.73 |
| Humerus X-ray | CPT 73060 | $158.36 |
| Hand X-ray 3 views | CPT 73130 | $301.85 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,725.32 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,725.32 |
| Knee X-ray 1-2 views | CPT 73560 | $234.6 |
| Ankle X-ray 3 views | CPT 73610 | $352.29 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,159.78 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,725.32 |
| CT abdomen without contrast | CPT 74150 | $1,137.23 |
| CT abdomen with contrast | CPT 74160 | $1,333.06 |
| CT abdomen with and without contrast | CPT 74170 | $1,614.09 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,289.37 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,643.33 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,186.43 |
| MRI abdomen without contrast | CPT 74181 | $1,589.55 |
| MRI abdomen with and without contrast | CPT 74183 | $2,662.43 |
| Abdominal ultrasound complete | CPT 76700 | $1,016.5 |
| Abdominal ultrasound limited | CPT 76705 | $1,016.5 |
| Retroperitoneal ultrasound complete | CPT 76770 | $330.65 |
| Obstetric ultrasound first trimester | CPT 76801 | $634.53 |
| Obstetric ultrasound after first trimester | CPT 76805 | $634.53 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,016.95 |
| Transvaginal ultrasound | CPT 76830 | $395.37 |
| Pelvic ultrasound complete | CPT 76856 | $750.25 |
| Scrotal ultrasound | CPT 76870 | $560.39 |
| Diagnostic mammography unilateral | CPT 77065 | $358.4 |
| Diagnostic mammography bilateral | CPT 77066 | $394 |
| Screening mammography bilateral | CPT 77067 | $136.8 |
| EKG tracing only | CPT 93005 | $121.82 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,205.46 |
| Transthoracic echocardiogram | CPT 93307 | $622.44 |
| Stress echocardiogram | CPT 93350 | $1,787.95 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,343 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,563.42 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,002.06 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,858 |
| COPD w MCC | MS-DRG 190 | $9,470.42 |
| COPD w CC | MS-DRG 191 | $9,470.42 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,470.42 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,942.2 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,569.51 |
| AMI discharged alive w MCC | MS-DRG 280 | $9,470.42 |
| AMI discharged alive w CC | MS-DRG 281 | $9,470.42 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,470.42 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,690 |
| Heart failure & shock w CC | MS-DRG 292 | $7,275.68 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,085.93 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,470.42 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,470.42 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,470.42 |
| GI hemorrhage w CC | MS-DRG 378 | $8,326.15 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,584.24 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,738.67 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,896 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,729.48 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,970.04 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,810 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,664.48 |
| Basic metabolic panel (BMP) | CPT 80048 | $102.54 |
| Electrolyte panel | CPT 80051 | $46.8 |
| Comprehensive metabolic panel | CPT 80053 | $127.97 |
| Lipid panel | CPT 80061 | $56.09 |
| Renal function panel | CPT 80069 | $119.51 |
| Hepatic function panel | CPT 80076 | $91.36 |
| Urinalysis non-automated | CPT 81002 | $16.25 |
| Urinalysis automated | CPT 81003 | $38.55 |
| Glucose quantitative | CPT 82947 | $19.09 |
| Hemoglobin A1c | CPT 83036 | $41.68 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $65.05 |
| Complete blood count with automated differential | CPT 85025 | $31.12 |
| Complete blood count without differential | CPT 85027 | $26.32 |
| Urine culture bacterial | CPT 87086 | $31.16 |
| Urine culture identification | CPT 87088 | $39.34 |
| Tissue exam by pathologist level IV | CPT 88305 | $148.4 |
| Fetal non-stress test | CPT 59025 | $489.2 |
| Office visit, new patient, 15-29 min | CPT 99202 | $173.6 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $225.6 |
| Office visit, new patient, 45-59 min | CPT 99204 | $287.97 |
| Office visit, new patient, 60-74 min | CPT 99205 | $343.78 |
| Office visit, established patient, 5 min | CPT 99211 | $92.12 |
| Office visit, established patient, 10-19 min | CPT 99212 | $123.48 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $141.12 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $164.75 |
| Office visit, established patient, 40-54 min | CPT 99215 | $179.2 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | $491.32 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,217.19 |
| Colonoscopy diagnostic | CPT 45378 | $977.5 |
| Colonoscopy with biopsy | CPT 45380 | $1,609.53 |
| Colonoscopy with polyp removal | CPT 45385 | $1,609.53 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $9,470.42 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $9,470.42 |
| Total hip replacement | CPT 27130 | $12,880 |
| Total knee replacement | CPT 27447 | $12,880 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,817.25 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,083.12 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,769.48 |
| ACL reconstruction | CPT 29888 | $7,083.12 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $36,441 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,345 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,792 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,860 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,327 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $27,195 |
| Laparoscopic appendectomy | CPT 44970 | $5,784.86 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $9,470.42 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $9,470.42 |
| Major joint replacement w MCC | MS-DRG 469 | $24,289 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,704 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,784.86 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,784.86 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,349 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,992 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,389 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,784.86 |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,155 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,150 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,435 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,354 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,562 |
