| Psychoses | MS-DRG 885 | $11,532 |
| ED visit level 1 | CPT 99281 | $169.26 |
| ED visit level 2 | CPT 99282 | $369.92 |
| ED visit level 3 | CPT 99283 | $498.78 |
| ED visit level 4 | CPT 99284 | $634.78 |
| ED visit level 5 | CPT 99285 | $776.9 |
| Critical care, first hour | CPT 99291 | $883.66 |
| CT head without contrast | CPT 70450 | $1,055.7 |
| CT head with contrast | CPT 70460 | $1,653.08 |
| CT head with and without contrast | CPT 70470 | $1,837.36 |
| CT neck with contrast | CPT 70491 | $1,653.08 |
| MRI brain without contrast | CPT 70551 | $2,226.49 |
| MRI brain with contrast | CPT 70552 | $2,833.1 |
| MRI brain with and without contrast | CPT 70553 | $3,684.4 |
| Chest X-ray single view | CPT 71045 | $239.91 |
| Chest X-ray 2 views | CPT 71046 | $239.91 |
| Chest X-ray 3 views | CPT 71047 | $239.91 |
| CT chest without contrast | CPT 71250 | $1,089.86 |
| CT chest with contrast | CPT 71260 | $1,653.08 |
| CT chest with and without contrast | CPT 71270 | $1,837.36 |
| MRI chest without contrast | CPT 71550 | $2,241.94 |
| MRI chest with and without contrast | CPT 71552 | $3,580.76 |
| Lumbosacral spine X-ray | CPT 72100 | $247.18 |
| CT cervical spine without contrast | CPT 72125 | $1,089.86 |
| CT thoracic spine without contrast | CPT 72128 | $1,089.86 |
| CT lumbar spine without contrast | CPT 72131 | $1,089.86 |
| MRI cervical spine without contrast | CPT 72141 | $2,241.94 |
| MRI thoracic spine without contrast | CPT 72146 | $2,269.25 |
| MRI lumbar spine without contrast | CPT 72148 | $2,269.25 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,833.1 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,694.3 |
| MRI lumbar spine with contrast | CPT 72158 | $3,684.4 |
| CT pelvis without contrast | CPT 72192 | $1,089.86 |
| CT pelvis with contrast | CPT 72193 | $1,653.08 |
| Shoulder X-ray | CPT 73030 | $276.26 |
| Humerus X-ray | CPT 73060 | $276.26 |
| Hand X-ray 3 views | CPT 73130 | $276.26 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,495.84 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,938.32 |
| Knee X-ray 1-2 views | CPT 73560 | $276.26 |
| Ankle X-ray 3 views | CPT 73610 | $276.26 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,495.84 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,938.32 |
| CT abdomen without contrast | CPT 74150 | $1,089.86 |
| CT abdomen with contrast | CPT 74160 | $1,653.08 |
| CT abdomen with and without contrast | CPT 74170 | $1,837.36 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,299.4 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,295.19 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,295.19 |
| MRI abdomen without contrast | CPT 74181 | $2,241.94 |
| MRI abdomen with and without contrast | CPT 74183 | $3,580.76 |
| Abdominal ultrasound complete | CPT 76700 | $700.4 |
| Abdominal ultrasound limited | CPT 76705 | $508.3 |
| Retroperitoneal ultrasound complete | CPT 76770 | $680.34 |
| Obstetric ultrasound first trimester | CPT 76801 | $739.5 |
| Transvaginal ultrasound | CPT 76830 | $567.8 |
| Pelvic ultrasound complete | CPT 76856 | $567.8 |
| Scrotal ultrasound | CPT 76870 | $547.4 |
| Diagnostic mammography unilateral | CPT 77065 | $218.79 |
| EKG tracing only | CPT 93005 | $57.2 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,067.59 |
| Transthoracic echocardiogram | CPT 93307 | $570 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,755 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,593.51 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,935.47 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,099 |
| COPD w MCC | MS-DRG 190 | $10,293 |
| COPD w CC | MS-DRG 191 | $10,293 |
| COPD w/o CC/MCC | MS-DRG 192 | $10,293 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,926.44 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,479.55 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,293 |
| AMI discharged alive w CC | MS-DRG 281 | $10,293 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,293 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,824 |
| Heart failure & shock w CC | MS-DRG 292 | $7,277.96 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,969.82 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,293 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,293 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $10,293 |
| GI hemorrhage w CC | MS-DRG 378 | $8,352.07 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,495.07 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,711.91 |
| Fractures of femur w/o MCC | MS-DRG 533 | $13,140 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,816.9 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,955.77 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,196 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,699.51 |
| Basic metabolic panel (BMP) | CPT 80048 | $99.28 |
| Electrolyte panel | CPT 80051 | $78.54 |
| Comprehensive metabolic panel | CPT 80053 | $122.4 |
| Lipid panel | CPT 80061 | $120.36 |
| Renal function panel | CPT 80069 | $101.32 |
| Hepatic function panel | CPT 80076 | $95.2 |
| Urinalysis non-automated | CPT 81002 | $30.26 |
| Urinalysis automated | CPT 81003 | $26.52 |
| Glucose quantitative | CPT 82947 | $33.32 |
| Hemoglobin A1c | CPT 83036 | $89.76 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $142.46 |
| Complete blood count with automated differential | CPT 85025 | $65.62 |
| Complete blood count without differential | CPT 85027 | $54.74 |
| Urine culture bacterial | CPT 87086 | $66.98 |
| Tissue exam by pathologist level IV | CPT 88305 | $149.53 |
| Vaginal delivery only | CPT 59409 | $4,007.25 |
| Office visit, new patient, 15-29 min | CPT 99202 | $166.14 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $214.5 |
| Office visit, new patient, 45-59 min | CPT 99204 | $276.51 |
| Office visit, new patient, 60-74 min | CPT 99205 | $335.4 |
| Office visit, established patient, 10-19 min | CPT 99212 | $90.09 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $121.29 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $140.4 |
| Office visit, established patient, 40-54 min | CPT 99215 | $164.97 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,452.36 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,945.14 |
| Sigmoidoscopy diagnostic | CPT 45330 | $398.8 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,452.36 |
| Colonoscopy diagnostic | CPT 45378 | $975 |
| Colonoscopy with biopsy | CPT 45380 | $1,945.14 |
| Colonoscopy with polyp removal | CPT 45385 | $1,945.14 |
| Total shoulder arthroplasty | CPT 23472 | $17,746 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $10,293 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $10,293 |
| Total hip replacement | CPT 27130 | $12,880 |
| Total knee replacement | CPT 27447 | $13,003 |
| Knee revision arthroplasty single component | CPT 27486 | $7,054.31 |
| Knee revision arthroplasty all components | CPT 27487 | $9,031.71 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,490.83 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,151.22 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,131.83 |
| ACL reconstruction | CPT 29888 | $6,957.8 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $37,842 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,905 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,079 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,150 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,493 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $28,142 |
| Laparoscopic appendectomy | CPT 44970 | $5,840.48 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $10,293 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $10,293 |
| Major joint replacement w MCC | MS-DRG 469 | $25,092 |
| Major joint replacement w/o MCC | MS-DRG 470 | $16,086 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,840.48 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,840.48 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $24,106 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $17,436 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,656 |
| Lap inguinal hernia repair | CPT 49650 | $5,840.48 |
| Vaginal hysterectomy | CPT 58260 | $4,988.69 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,007.35 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,422 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,840.48 |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,903 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,405 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,656 |
| Complex cataract surgery | CPT 66982 | $2,348.35 |
| Cataract surgery with lens implant | CPT 66984 | $2,337.37 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,473 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $17,066 |
| PCI single major coronary artery | CPT 92920 | $10,278 |
| PCI with drug-eluting stent | CPT 92928 | $15,688 |
| PCI bypass graft | CPT 92937 | $15,688 |
| Coronary angiography with cath | CPT 93455 | $4,297.41 |
| Coronary angiography with bypass cath | CPT 93458 | $4,403.88 |
