| Psychoses | MS-DRG 885 | $8,093.82 |
| ED visit level 1 | CPT 99281 | $114.30 |
| ED visit level 2 | CPT 99282 | $188.30 |
| ED visit level 3 | CPT 99283 | $296.89 |
| ED visit level 4 | CPT 99284 | $439.26 |
| ED visit level 5 | CPT 99285 | $640.52 |
| Critical care, first hour | CPT 99291 | $550.40 |
| CT head without contrast | CPT 70450 | $382.77 |
| CT head with contrast | CPT 70460 | $622.34 |
| CT head with and without contrast | CPT 70470 | $819.08 |
| CT neck with contrast | CPT 70491 | $826.36 |
| MRI brain without contrast | CPT 70551 | $719.91 |
| MRI brain with contrast | CPT 70552 | $1,064.58 |
| MRI brain with and without contrast | CPT 70553 | $1,206.45 |
| Chest X-ray single view | CPT 71045 | $68.40 |
| Chest X-ray 2 views | CPT 71046 | $100.40 |
| Chest X-ray 3 views | CPT 71047 | $102.80 |
| CT chest without contrast | CPT 71250 | $466.78 |
| CT chest with contrast | CPT 71260 | $845.25 |
| CT chest with and without contrast | CPT 71270 | $976.37 |
| MRI chest without contrast | CPT 71550 | $1,141.28 |
| MRI chest with contrast | CPT 71551 | $1,125.45 |
| MRI chest with and without contrast | CPT 71552 | $1,953.40 |
| Lumbosacral spine X-ray | CPT 72100 | $114.00 |
| CT cervical spine without contrast | CPT 72125 | $470.42 |
| CT thoracic spine without contrast | CPT 72128 | $470.42 |
| CT lumbar spine without contrast | CPT 72131 | $466.78 |
| MRI cervical spine without contrast | CPT 72141 | $689.41 |
| MRI thoracic spine without contrast | CPT 72146 | $689.41 |
| MRI lumbar spine without contrast | CPT 72148 | $692.99 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,064.70 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,215.43 |
| MRI lumbar spine with contrast | CPT 72158 | $1,211.85 |
| CT pelvis without contrast | CPT 72192 | $465.02 |
| CT pelvis with contrast | CPT 72193 | $718.56 |
| Shoulder X-ray | CPT 73030 | $132.55 |
| Humerus X-ray | CPT 73060 | $117.70 |
| Hand X-ray 3 views | CPT 73130 | $128.70 |
| MRI upper extremity joint without contrast | CPT 73221 | $885.50 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,700.60 |
| Knee X-ray 1-2 views | CPT 73560 | $108.90 |
| Ankle X-ray 3 views | CPT 73610 | $128.70 |
| MRI lower extremity joint without contrast | CPT 73721 | $886.05 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,702.25 |
| CT abdomen without contrast | CPT 74150 | $459.63 |
| CT abdomen with contrast | CPT 74160 | $732.91 |
| CT abdomen with and without contrast | CPT 74170 | $888.14 |
| CT abdomen and pelvis without contrast | CPT 74176 | $597.54 |
| CT abdomen and pelvis with contrast | CPT 74177 | $954.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,232.00 |
| MRI abdomen without contrast | CPT 74181 | $728.94 |
| MRI abdomen with and without contrast | CPT 74183 | $1,348.32 |
| Abdominal ultrasound complete | CPT 76700 | $273.02 |
| Abdominal ultrasound limited | CPT 76705 | $198.49 |
| Retroperitoneal ultrasound complete | CPT 76770 | $270.00 |
| Obstetric ultrasound first trimester | CPT 76801 | $270.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $321.47 |
| Transvaginal ultrasound | CPT 76830 | $241.81 |
| Pelvic ultrasound complete | CPT 76856 | $221.76 |
| Scrotal ultrasound | CPT 76870 | $213.89 |
| Diagnostic mammography unilateral | CPT 77065 | $249.32 |
| Diagnostic mammography bilateral | CPT 77066 | $315.69 |
| Screening mammography bilateral | CPT 77067 | $263.77 |
| EKG complete | CPT 93000 | $75.56 |
| EKG tracing only | CPT 93005 | $75.56 |
| EKG interpretation only | CPT 93010 | $28.33 |
| Transthoracic echocardiogram complete | CPT 93306 | $536.14 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,425 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,065 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,353.20 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,658 |
| COPD w MCC | MS-DRG 190 | $8,539.82 |
| COPD w CC | MS-DRG 191 | $7,545.46 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,024.67 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,147.72 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,369.56 |
| AMI discharged alive w MCC | MS-DRG 280 | $12,821 |
| AMI discharged alive w CC | MS-DRG 281 | $8,843.98 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,500.16 |
| Heart failure & shock w MCC | MS-DRG 291 | $9,908.54 |
| Heart failure & shock w CC | MS-DRG 292 | $6,761.67 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,772.25 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,194.93 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,790.70 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,527.28 |
| GI hemorrhage w CC | MS-DRG 378 | $9,007.76 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,237.02 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,071.46 |
| Fractures of femur w/o MCC | MS-DRG 533 | $16,550 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,669 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,837.50 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,401 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,376.05 |
| Initial hospital care, low complexity | CPT 99221 | $153.75 |
| Initial hospital care, moderate complexity | CPT 99222 | $282.80 |
| Initial hospital care, high complexity | CPT 99223 | $405.30 |
| Basic metabolic panel (BMP) | CPT 80048 | $41.13 |
| Electrolyte panel | CPT 80051 | $33.57 |
| Comprehensive metabolic panel | CPT 80053 | $50.80 |
| Lipid panel | CPT 80061 | $53.00 |
| Renal function panel | CPT 80069 | $41.73 |
| Hepatic function panel | CPT 80076 | $39.92 |
| Urinalysis non-automated | CPT 81002 | $13.20 |
| Urinalysis automated | CPT 81003 | $10.43 |
| Glucose quantitative | CPT 82947 | $18.22 |
| Hemoglobin A1c | CPT 83036 | $45.01 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $52.40 |
| Complete blood count with automated differential | CPT 85025 | $28.40 |
| Complete blood count without differential | CPT 85027 | $26.32 |
| Urine culture bacterial | CPT 87086 | $37.41 |
| Urine culture identification | CPT 87088 | $37.50 |
| Tissue exam by pathologist level IV | CPT 88305 | $100.13 |
| Vaginal delivery only | CPT 59409 | $1,979.20 |
| C-section delivery only | CPT 59514 | $2,193.00 |
| C-section with postpartum | CPT 59515 | $2,648.95 |
| Office visit, new patient, 15-29 min | CPT 99202 | $93.03 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $136.99 |
| Office visit, new patient, 45-59 min | CPT 99204 | $211.68 |
| Office visit, new patient, 60-74 min | CPT 99205 | $265.20 |
| Office visit, established patient, 5 min | CPT 99211 | $81.93 |
| Office visit, established patient, 10-19 min | CPT 99212 | $56.12 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $92.23 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $137.59 |
| Office visit, established patient, 40-54 min | CPT 99215 | $185.37 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,024.80 |
| Upper GI endoscopy with biopsy | CPT 43239 | $796.50 |
| Sigmoidoscopy diagnostic | CPT 45330 | $220.50 |
| Sigmoidoscopy with biopsy | CPT 45331 | $280.80 |
| Colonoscopy diagnostic | CPT 45378 | $761.25 |
| Colonoscopy with biopsy | CPT 45380 | $909.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,078.50 |
| Total shoulder arthroplasty | CPT 23472 | $3,842.40 |
| Total hip replacement | CPT 27130 | — |
| Total knee replacement | CPT 27447 | $4,362.40 |
| Knee revision arthroplasty single component | CPT 27486 | $3,433.25 |
| Knee revision arthroplasty all components | CPT 27487 | $4,393.48 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,597.20 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | — |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,912.40 |
| ACL reconstruction | CPT 29888 | $3,461.50 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $33,691 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $20,718 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,571 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,927 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,412 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $36,091 |
| Open appendectomy | CPT 44950 | — |
| Laparoscopic appendectomy | CPT 44970 | $1,073.60 |
| Major joint replacement w MCC | MS-DRG 469 | $25,982 |
| Major joint replacement w/o MCC | MS-DRG 470 | $14,108 |
| Laparoscopic cholecystectomy | CPT 47562 | — |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,446.40 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,281 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,340 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,149 |
| Open umbilical hernia repair | CPT 49560 | $1,470.59 |
| Umbilical hernia repair age 5+ | CPT 49585 | $698.60 |
| Lap inguinal hernia repair | CPT 49650 | $1,028.80 |
| Lap incisional hernia repair | CPT 49652 | $1,626.10 |
| Total abdominal hysterectomy | CPT 58150 | — |
| Vaginal hysterectomy | CPT 58260 | — |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $2,055.00 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $4,385.69 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,618.40 |
| OR procedure for obesity w MCC | MS-DRG 619 | $25,596 |
| OR procedure for obesity w CC | MS-DRG 620 | $14,939 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,061 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,213 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $13,520 |
