| Psychoses | MS-DRG 885 | $9,598.26 |
| ED visit level 1 | CPT 99281 | $143.69 |
| ED visit level 2 | CPT 99282 | $428 |
| ED visit level 3 | CPT 99283 | $175.17 |
| ED visit level 4 | CPT 99284 | $2,180 |
| ED visit level 5 | CPT 99285 | $2,880 |
| Critical care, first hour | CPT 99291 | $3,276 |
| CT head without contrast | CPT 70450 | $2,420.6 |
| CT head with contrast | CPT 70460 | $2,651.94 |
| CT head with and without contrast | CPT 70470 | $3,230.97 |
| CT neck with contrast | CPT 70491 | $3,206 |
| MRI brain without contrast | CPT 70551 | $758.5 |
| MRI brain with contrast | CPT 70552 | $825.2 |
| MRI brain with and without contrast | CPT 70553 | $5,180 |
| Chest X-ray single view | CPT 71045 | $428.4 |
| Chest X-ray 2 views | CPT 71046 | $491.08 |
| Chest X-ray 3 views | CPT 71047 | $492.8 |
| CT chest without contrast | CPT 71250 | $2,338.88 |
| CT chest with contrast | CPT 71260 | $825.2 |
| CT chest with and without contrast | CPT 71270 | $825.2 |
| MRI chest without contrast | CPT 71550 | $3,067.04 |
| MRI chest with contrast | CPT 71551 | $2,102.18 |
| MRI chest with and without contrast | CPT 71552 | $4,579.41 |
| Lumbosacral spine X-ray | CPT 72100 | $644.74 |
| CT cervical spine without contrast | CPT 72125 | $2,493.3 |
| CT thoracic spine without contrast | CPT 72128 | $2,493.3 |
| CT lumbar spine without contrast | CPT 72131 | $373.71 |
| MRI cervical spine without contrast | CPT 72141 | $758.5 |
| MRI thoracic spine without contrast | CPT 72146 | $758.5 |
| MRI lumbar spine without contrast | CPT 72148 | $758.5 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,490.05 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,490.05 |
| MRI lumbar spine with contrast | CPT 72158 | $1,490.05 |
| CT pelvis without contrast | CPT 72192 | $373.71 |
| CT pelvis with contrast | CPT 72193 | $825.2 |
| Shoulder X-ray | CPT 73030 | $544.46 |
| Humerus X-ray | CPT 73060 | $154.37 |
| Hand X-ray 3 views | CPT 73130 | $154.37 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,568.6 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $4,866.95 |
| Knee X-ray 1-2 views | CPT 73560 | $404.78 |
| Ankle X-ray 3 views | CPT 73610 | $154.37 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,719.8 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,490.05 |
| CT abdomen without contrast | CPT 74150 | $373.71 |
| CT abdomen with contrast | CPT 74160 | $825.2 |
| CT abdomen with and without contrast | CPT 74170 | $825.2 |
| CT abdomen and pelvis without contrast | CPT 74176 | $4,496.8 |
| CT abdomen and pelvis with contrast | CPT 74177 | $825.2 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $5,137.3 |
| MRI abdomen without contrast | CPT 74181 | $758.5 |
| MRI abdomen with and without contrast | CPT 74183 | $1,490.05 |
| Abdominal ultrasound complete | CPT 76700 | $309.05 |
| Abdominal ultrasound limited | CPT 76705 | $294.75 |
| Retroperitoneal ultrasound complete | CPT 76770 | $309.05 |
| Obstetric ultrasound first trimester | CPT 76801 | $203.5 |
| Obstetric ultrasound after first trimester | CPT 76805 | $253.89 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,388.8 |
| Transvaginal ultrasound | CPT 76830 | $906.78 |
| Pelvic ultrasound complete | CPT 76856 | $309.05 |
| Scrotal ultrasound | CPT 76870 | $309.05 |
| Diagnostic mammography unilateral | CPT 77065 | $295.4 |
| Diagnostic mammography bilateral | CPT 77066 | $376.6 |
| Screening mammography bilateral | CPT 77067 | $268.8 |
| EKG tracing only | CPT 93005 | $449.4 |
| Transthoracic echocardiogram complete | CPT 93306 | $3,383.1 |
| Transthoracic echocardiogram | CPT 93307 | $228.81 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $14,664 |
| COPD w MCC | MS-DRG 190 | $8,896.62 |
| COPD w CC | MS-DRG 191 | $6,963.45 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,509.03 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,876.48 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,287.14 |
| AMI discharged alive w MCC | MS-DRG 280 | $12,765 |
| AMI discharged alive w CC | MS-DRG 281 | $7,466.78 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $5,740.4 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,530 |
| Heart failure & shock w CC | MS-DRG 292 | $7,060.59 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,126.08 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,346.85 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,903.29 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,379.9 |
| GI hemorrhage w CC | MS-DRG 378 | $7,760.59 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,030.79 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,977.36 |
| Fractures of femur w/o MCC | MS-DRG 533 | $11,277 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,741.09 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,201.87 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $14,632 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,084.3 |
| Basic metabolic panel (BMP) | CPT 80048 | $21 |
| Electrolyte panel | CPT 80051 | $13.47 |
| Comprehensive metabolic panel | CPT 80053 | $8.4 |
| Lipid panel | CPT 80061 | $11.9 |
| Renal function panel | CPT 80069 | $379.4 |
| Hepatic function panel | CPT 80076 | $345.6 |
| Urinalysis automated | CPT 81003 | $62.3 |
| Glucose quantitative | CPT 82947 | $5.6 |
| Hemoglobin A1c | CPT 83036 | $8.4 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $263.2 |
| Complete blood count with automated differential | CPT 85025 | $232.4 |
| Complete blood count without differential | CPT 85027 | $11.9 |
| Urine culture bacterial | CPT 87086 | $20.3 |
| Tissue exam by pathologist level IV | CPT 88305 | $153.33 |
| Fetal non-stress test | CPT 59025 | $43.29 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $3,010.63 |
| Vaginal delivery only | CPT 59409 | $3,090.97 |
| Vaginal delivery with postpartum | CPT 59410 | $1,504.31 |
| Routine obstetric care with C-section | CPT 59510 | $3,339.23 |
| C-section delivery only | CPT 59514 | $1,363.82 |
| C-section with postpartum | CPT 59515 | $1,827.38 |
| Office visit, new patient, 15-29 min | CPT 99202 | $287 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $333.9 |
| Office visit, new patient, 45-59 min | CPT 99204 | $441.7 |
| Office visit, new patient, 60-74 min | CPT 99205 | $536.9 |
| Office visit, established patient, 5 min | CPT 99211 | $185.5 |
| Office visit, established patient, 10-19 min | CPT 99212 | $248.5 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $305.9 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $359.8 |
| Office visit, established patient, 40-54 min | CPT 99215 | $488.6 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,130.11 |
| Upper GI endoscopy with biopsy | CPT 43239 | $378.8 |
| Sigmoidoscopy diagnostic | CPT 45330 | $275.42 |
| Sigmoidoscopy with biopsy | CPT 45331 | $368.24 |
| Colonoscopy diagnostic | CPT 45378 | $368.24 |
| Colonoscopy with biopsy | CPT 45380 | $488.58 |
| Colonoscopy with polyp removal | CPT 45385 | $488.58 |
| Total shoulder arthroplasty | CPT 23472 | $2,171.06 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $24,704 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $15,787 |
| Hip hemiarthroplasty | CPT 27125 | $1,690.44 |
| Total hip replacement | CPT 27130 | $2,023.78 |
| Total knee replacement | CPT 27447 | $13,767 |
| Knee revision arthroplasty single component | CPT 27486 | $2,098.2 |
| Knee revision arthroplasty all components | CPT 27487 | $2,624.3 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,293 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,329.7 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,293.79 |
| ACL reconstruction | CPT 29888 | $1,710.18 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $38,262 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,843 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,308 |
| CABG single arterial graft | CPT 33533 | $2,793.8 |
| CABG 2 arterial grafts | CPT 33534 | $3,104.23 |
| CABG 3 arterial grafts | CPT 33535 | $3,458.58 |
| CABG 4+ arterial grafts | CPT 33536 | $3,714.83 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,144 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $10,269 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $27,186 |
| Open appendectomy | CPT 44950 | $3,959.18 |
| Laparoscopic appendectomy | CPT 44970 | $6,104.6 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $53,287 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $30,941 |
| Major joint replacement w MCC | MS-DRG 469 | $24,417 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,192 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,977.62 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,977.62 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,675 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,387 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $12,898 |
| Open umbilical hernia repair | CPT 49560 | $1,377.56 |
| Umbilical hernia repair age 5+ | CPT 49585 | $1,377.56 |
| Lap inguinal hernia repair | CPT 49650 | $1,976.68 |
| Lap incisional hernia repair | CPT 49652 | $1,977.62 |
| Total abdominal hysterectomy | CPT 58150 | $1,496.13 |
| Vaginal hysterectomy | CPT 58260 | $1,858.9 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $1,977.62 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $2,333.18 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,977.62 |
| OR procedure for obesity w MCC | MS-DRG 619 | $24,066 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,949 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,402 |
| Complex cataract surgery | CPT 66982 | $1,001.97 |
| Cataract surgery with lens implant | CPT 66984 | $1,001.97 |
| Intravitreal injection | CPT 67028 | $275.42 |
| Vitrectomy mechanical | CPT 67042 | $1,701.07 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $8,945.14 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $13,821 |
| PCI single major coronary artery | CPT 92920 | $13,658 |
| PCI with drug-eluting stent | CPT 92928 | $17,534 |
| PCI bypass graft | CPT 92937 | $16,504 |
| Left heart catheterization | CPT 93452 | $26,716 |
| Coronary angiography with cath | CPT 93455 | $20,654 |
| Coronary angiography with bypass cath | CPT 93458 | $34,173 |
