| Psychoses | MS-DRG 885 | $12,401 |
| ED visit level 1 | CPT 99281 | $277.86 |
| ED visit level 2 | CPT 99282 | $358.66 |
| ED visit level 3 | CPT 99283 | $655.96 |
| ED visit level 4 | CPT 99284 | $1,096.62 |
| ED visit level 5 | CPT 99285 | $1,135.23 |
| Critical care, first hour | CPT 99291 | $1,583.83 |
| CT head without contrast | CPT 70450 | $1,412.96 |
| CT head with contrast | CPT 70460 | $2,090.61 |
| CT head with and without contrast | CPT 70470 | $2,271.53 |
| CT neck with contrast | CPT 70491 | $2,208.32 |
| MRI brain without contrast | CPT 70551 | $2,114.41 |
| MRI brain with contrast | CPT 70552 | $2,430.35 |
| MRI brain with and without contrast | CPT 70553 | $3,176.34 |
| Chest X-ray single view | CPT 71045 | $154.47 |
| Chest X-ray 2 views | CPT 71046 | $511.54 |
| Chest X-ray 3 views | CPT 71047 | $440.13 |
| CT chest without contrast | CPT 71250 | $1,978.99 |
| CT chest with contrast | CPT 71260 | $2,237.76 |
| CT chest with and without contrast | CPT 71270 | $2,632.25 |
| MRI chest without contrast | CPT 71550 | $2,208.32 |
| MRI chest with contrast | CPT 71551 | $2,547.59 |
| MRI chest with and without contrast | CPT 71552 | $3,328.14 |
| Lumbosacral spine X-ray | CPT 72100 | $367.65 |
| CT cervical spine without contrast | CPT 72125 | $1,858.91 |
| CT thoracic spine without contrast | CPT 72128 | $1,828.75 |
| CT lumbar spine without contrast | CPT 72131 | $1,808.65 |
| MRI cervical spine without contrast | CPT 72141 | $2,137.16 |
| MRI thoracic spine without contrast | CPT 72146 | $2,208.32 |
| MRI lumbar spine without contrast | CPT 72148 | $2,208.32 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,547.59 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,229.45 |
| MRI lumbar spine with contrast | CPT 72158 | $3,348.68 |
| CT pelvis without contrast | CPT 72192 | $1,157.98 |
| CT pelvis with contrast | CPT 72193 | $1,676.93 |
| Shoulder X-ray | CPT 73030 | $337.92 |
| Humerus X-ray | CPT 73060 | $623.7 |
| Hand X-ray 3 views | CPT 73130 | $324.06 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,329.64 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,716.3 |
| Knee X-ray 1-2 views | CPT 73560 | $669.24 |
| Ankle X-ray 3 views | CPT 73610 | $337.92 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,329.64 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,716.3 |
| CT abdomen without contrast | CPT 74150 | $1,917.62 |
| CT abdomen with contrast | CPT 74160 | $2,315.52 |
| CT abdomen with and without contrast | CPT 74170 | $2,902.79 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,772.53 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,718.42 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $4,779.04 |
| MRI abdomen without contrast | CPT 74181 | $2,208.32 |
| MRI abdomen with and without contrast | CPT 74183 | $3,348.68 |
| Abdominal ultrasound complete | CPT 76700 | $808.31 |
| Abdominal ultrasound limited | CPT 76705 | $608.88 |
| Retroperitoneal ultrasound complete | CPT 76770 | $645.91 |
| Obstetric ultrasound first trimester | CPT 76801 | $608.88 |
| Obstetric ultrasound after first trimester | CPT 76805 | $608.88 |
| Transvaginal ultrasound | CPT 76830 | $598.3 |
| Pelvic ultrasound complete | CPT 76856 | $645.38 |
| Scrotal ultrasound | CPT 76870 | $569.73 |
| Diagnostic mammography unilateral | CPT 77065 | $293.57 |
| Diagnostic mammography bilateral | CPT 77066 | $447.58 |
| Screening mammography bilateral | CPT 77067 | $220.18 |
| EKG tracing only | CPT 93005 | $239.64 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,996.97 |
| Transthoracic echocardiogram | CPT 93307 | $748.01 |
| Stress echocardiogram | CPT 93350 | $808.98 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $30,069 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $16,243 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $11,003 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $23,270 |
| COPD w MCC | MS-DRG 190 | $16,103 |
| COPD w CC | MS-DRG 191 | $13,204 |
| COPD w/o CC/MCC | MS-DRG 192 | $10,308 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $12,563 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $9,611.87 |
| AMI discharged alive w MCC | MS-DRG 280 | $23,731 |
| AMI discharged alive w CC | MS-DRG 281 | $14,777 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $11,626 |
| Heart failure & shock w MCC | MS-DRG 291 | $18,673 |
| Heart failure & shock w CC | MS-DRG 292 | $12,538 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $9,099.85 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $17,423 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,803 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,377.14 |
| GI hemorrhage w CC | MS-DRG 378 | $15,569 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $10,135 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $11,388 |
| Fractures of femur w/o MCC | MS-DRG 533 | $25,205 |
| Kidney/UTI w MCC | MS-DRG 689 | $18,431 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $11,402 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $29,531 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $15,317 |
| Basic metabolic panel (BMP) | CPT 80048 | $159.85 |
| Electrolyte panel | CPT 80051 | $112.05 |
| Comprehensive metabolic panel | CPT 80053 | $184.53 |
| Lipid panel | CPT 80061 | $195.32 |
| Renal function panel | CPT 80069 | $133.64 |
| Hepatic function panel | CPT 80076 | $198.92 |
| Urinalysis non-automated | CPT 81002 | $43.69 |
| Urinalysis automated | CPT 81003 | $32.38 |
| Glucose quantitative | CPT 82947 | $44.72 |
| Hemoglobin A1c | CPT 83036 | $141.86 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $384.47 |
| Complete blood count with automated differential | CPT 85025 | $81.73 |
| Complete blood count without differential | CPT 85027 | $68.88 |
| Urine culture bacterial | CPT 87086 | $187.1 |
| Urine culture identification | CPT 87088 | $65.79 |
| Tissue exam by pathologist level IV | CPT 88305 | $214.34 |
| Vaginal delivery only | CPT 59409 | $1,136.02 |
| Office visit, established patient, 5 min | CPT 99211 | $101.57 |
| Upper GI endoscopy diagnostic | CPT 43235 | $2,944.38 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,944.38 |
| Sigmoidoscopy diagnostic | CPT 45330 | $581.37 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,635.76 |
| Colonoscopy diagnostic | CPT 45378 | $1,457.92 |
| Colonoscopy with biopsy | CPT 45380 | $2,715.92 |
| Colonoscopy with polyp removal | CPT 45385 | $2,715.92 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $65,236 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $36,877 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $26,819 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $26,301 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $21,562 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $54,778 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $2,261.92 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $2,261.92 |
| Major joint replacement w MCC | MS-DRG 469 | $46,450 |
| Major joint replacement w/o MCC | MS-DRG 470 | $27,349 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $46,822 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $33,674 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $26,045 |
| OR procedure for obesity w MCC | MS-DRG 619 | $44,999 |
| OR procedure for obesity w CC | MS-DRG 620 | $25,623 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $22,319 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $18,623 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $23,532 |
