| Psychoses | MS-DRG 885 | $10,888 |
| ED visit level 1 | CPT 99281 | $90.09 |
| ED visit level 2 | CPT 99282 | $163.29 |
| ED visit level 3 | CPT 99283 | $287.37 |
| ED visit level 4 | CPT 99284 | $451.34 |
| ED visit level 5 | CPT 99285 | $647.85 |
| Critical care, first hour | CPT 99291 | $859.49 |
| CT head without contrast | CPT 70450 | $137.97 |
| CT head with contrast | CPT 70460 | $225.32 |
| CT head with and without contrast | CPT 70470 | $225.32 |
| CT neck with contrast | CPT 70491 | $230.41 |
| MRI brain without contrast | CPT 70551 | $2,314.00 |
| MRI brain with contrast | CPT 70552 | $2,511.50 |
| MRI brain with and without contrast | CPT 70553 | $3,227.50 |
| Chest X-ray single view | CPT 71045 | $83.91 |
| Chest X-ray 2 views | CPT 71046 | $350.04 |
| CT chest without contrast | CPT 71250 | $139.15 |
| CT chest with contrast | CPT 71260 | $227.07 |
| CT chest with and without contrast | CPT 71270 | $246.37 |
| MRI chest without contrast | CPT 71550 | $2,000.50 |
| MRI chest with contrast | CPT 71551 | $737.12 |
| MRI chest with and without contrast | CPT 71552 | $506.66 |
| Lumbosacral spine X-ray | CPT 72100 | $137.97 |
| CT cervical spine without contrast | CPT 72125 | $2,068.50 |
| CT thoracic spine without contrast | CPT 72128 | $1,968.00 |
| CT lumbar spine without contrast | CPT 72131 | $2,100.50 |
| MRI cervical spine without contrast | CPT 72141 | $289.46 |
| MRI thoracic spine without contrast | CPT 72146 | $289.46 |
| MRI lumbar spine without contrast | CPT 72148 | $289.46 |
| MRI lumbar spine with and without contrast | CPT 72149 | $467.79 |
| MRI cervical spine with and without contrast | CPT 72156 | $467.79 |
| MRI lumbar spine with contrast | CPT 72158 | $467.79 |
| CT pelvis without contrast | CPT 72192 | $1,655.50 |
| CT pelvis with contrast | CPT 72193 | $241.63 |
| Shoulder X-ray | CPT 73030 | $366.05 |
| Humerus X-ray | CPT 73060 | $278.82 |
| Hand X-ray 3 views | CPT 73130 | $260.04 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,132.50 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,889.50 |
| Knee X-ray 1-2 views | CPT 73560 | $100.65 |
| Ankle X-ray 3 views | CPT 73610 | $309.73 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,185.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,874.50 |
| CT abdomen without contrast | CPT 74150 | $1,964.00 |
| CT abdomen with contrast | CPT 74160 | $2,367.50 |
| CT abdomen with and without contrast | CPT 74170 | $2,030.50 |
| CT abdomen and pelvis without contrast | CPT 74176 | $288.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $391.89 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $391.89 |
| MRI abdomen without contrast | CPT 74181 | $289.46 |
| MRI abdomen with and without contrast | CPT 74183 | $479.32 |
| Abdominal ultrasound complete | CPT 76700 | $139.15 |
| Abdominal ultrasound limited | CPT 76705 | $137.97 |
| Retroperitoneal ultrasound complete | CPT 76770 | $137.97 |
| Obstetric ultrasound first trimester | CPT 76801 | $131.69 |
| Obstetric ultrasound after first trimester | CPT 76805 | $139.15 |
| Transvaginal ultrasound | CPT 76830 | $139.15 |
| Pelvic ultrasound complete | CPT 76856 | $137.97 |
| Scrotal ultrasound | CPT 76870 | $137.97 |
| Diagnostic mammography unilateral | CPT 77065 | $245.14 |
| Diagnostic mammography bilateral | CPT 77066 | $393.10 |
| Screening mammography bilateral | CPT 77067 | $216.98 |
| EKG tracing only | CPT 93005 | $249.55 |
| Transthoracic echocardiogram complete | CPT 93306 | $497.71 |
| Transthoracic echocardiogram | CPT 93307 | $241.10 |
| Stress echocardiogram | CPT 93350 | $490.46 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $15,105 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $9,296.75 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,041.04 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $14,660 |
| COPD w MCC | MS-DRG 190 | $9,784.99 |
| COPD w CC | MS-DRG 191 | $8,187.06 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,934.86 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,051.69 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,737.11 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,164 |
| AMI discharged alive w CC | MS-DRG 281 | $8,677.43 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,137.26 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,140 |
| Heart failure & shock w CC | MS-DRG 292 | $8,278.94 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,233.45 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,469 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,299.18 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,029.72 |
| GI hemorrhage w CC | MS-DRG 378 | $9,129.87 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,547.32 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,400.70 |
| Fractures of femur w/o MCC | MS-DRG 533 | $11,857 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,903.30 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,587.83 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $14,809 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,328.39 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.88 |
| Electrolyte panel | CPT 80051 | $7.36 |
| Comprehensive metabolic panel | CPT 80053 | $11.09 |
| Lipid panel | CPT 80061 | $14.06 |
| Renal function panel | CPT 80069 | $9.11 |
| Hepatic function panel | CPT 80076 | $8.58 |
| Urinalysis automated | CPT 81003 | $2.36 |
| Glucose quantitative | CPT 82947 | $27.03 |
| Hemoglobin A1c | CPT 83036 | $10.20 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $17.64 |
| Complete blood count with automated differential | CPT 85025 | $80.56 |
| Complete blood count without differential | CPT 85027 | $72.08 |
| Urine culture bacterial | CPT 87086 | $8.47 |
| Urine culture identification | CPT 87088 | $8.49 |
| Tissue exam by pathologist level IV | CPT 88305 | $151.05 |
| Fetal non-stress test | CPT 59025 | $170.43 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $3,096.65 |
| Vaginal delivery only | CPT 59409 | $2,703.69 |
| Vaginal delivery with postpartum | CPT 59410 | $1,568.78 |
| Routine obstetric care with C-section | CPT 59510 | $3,434.63 |
| C-section delivery only | CPT 59514 | $1,363.82 |
| C-section with postpartum | CPT 59515 | $1,905.70 |
| Cesarean section w CC/MCC | MS-DRG 765 | $7,553.41 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $5,372.10 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $5,329.09 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $4,141.87 |
| Office visit, new patient, 15-29 min | CPT 99202 | $137.31 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $252.00 |
| Office visit, new patient, 45-59 min | CPT 99204 | $306.00 |
| Office visit, new patient, 60-74 min | CPT 99205 | $397.16 |
| Office visit, established patient, 5 min | CPT 99211 | $112.50 |
| Office visit, established patient, 10-19 min | CPT 99212 | $144.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $180.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $209.87 |
| Office visit, established patient, 40-54 min | CPT 99215 | $269.26 |
| Upper GI endoscopy diagnostic | CPT 43235 | $826.26 |
| Upper GI endoscopy with biopsy | CPT 43239 | $826.26 |
| Sigmoidoscopy diagnostic | CPT 45330 | $794.17 |
| Sigmoidoscopy with biopsy | CPT 45331 | $803.08 |
| Colonoscopy diagnostic | CPT 45378 | $803.08 |
| Colonoscopy with biopsy | CPT 45380 | $1,055.76 |
| Colonoscopy with polyp removal | CPT 45385 | $1,055.76 |
| Total shoulder arthroplasty | CPT 23472 | $12,323 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $23,052 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $15,523 |
| Hip hemiarthroplasty | CPT 27125 | $12,323 |
| Total hip replacement | CPT 27130 | $12,323 |
| Total knee replacement | CPT 27447 | $12,511 |
| Knee revision arthroplasty single component | CPT 27486 | $12,323 |
| Knee revision arthroplasty all components | CPT 27487 | $12,323 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,295.50 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,288.96 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,877.94 |
| ACL reconstruction | CPT 29888 | $6,269.08 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $34,743 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,236 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,773 |
| CABG single arterial graft | CPT 33533 | $2,793.80 |
| CABG 2 arterial grafts | CPT 33534 | $2,935.00 |
| CABG 3 arterial grafts | CPT 33535 | $2,935.00 |
| CABG 4+ arterial grafts | CPT 33536 | $2,935.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,632 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,214 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,094 |
| Open appendectomy | CPT 44950 | $3,281.08 |
| Laparoscopic appendectomy | CPT 44970 | $5,148.74 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $47,166 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $28,403 |
| Major joint replacement w MCC | MS-DRG 469 | $22,797 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,002 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,081.79 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,081.79 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,398 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,269 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,358 |
| Open umbilical hernia repair | CPT 49560 | $3,268.92 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,268.92 |
| Lap inguinal hernia repair | CPT 49650 | $5,063.78 |
| Lap incisional hernia repair | CPT 49652 | $5,063.78 |
| Total abdominal hysterectomy | CPT 58150 | $1,496.13 |
| Vaginal hysterectomy | CPT 58260 | $4,490.77 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,063.78 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $8,913.54 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,081.79 |
| OR procedure for obesity w MCC | MS-DRG 619 | $22,636 |
| OR procedure for obesity w CC | MS-DRG 620 | $14,107 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $13,037 |
| Complex cataract surgery | CPT 66982 | $2,125.63 |
| Cataract surgery with lens implant | CPT 66984 | $2,125.63 |
| Intravitreal injection | CPT 67028 | $310.96 |
| Vitrectomy mechanical | CPT 67042 | $4,014.30 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,031 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $14,319 |
| PCI single major coronary artery | CPT 92920 | $5,108.91 |
| PCI with drug-eluting stent | CPT 92928 | $10,351 |
| PCI bypass graft | CPT 92937 | $10,351 |
| Coronary angiography with cath | CPT 93455 | $3,939.04 |
| Coronary angiography with bypass cath | CPT 93458 | $3,939.04 |
