| ED visit level 1 | CPT 99281 | $309.38 |
| CT head without contrast | CPT 70450 | $2,674.35 |
| CT head with contrast | CPT 70460 | $4,132.01 |
| CT head with and without contrast | CPT 70470 | $4,602.6 |
| CT neck with contrast | CPT 70491 | $4,132.01 |
| MRI brain without contrast | CPT 70551 | $4,728.83 |
| MRI brain with contrast | CPT 70552 | $3,017.4 |
| MRI brain with and without contrast | CPT 70553 | $7,345.76 |
| Chest X-ray single view | CPT 71045 | $231.38 |
| Chest X-ray 2 views | CPT 71046 | $412.31 |
| Chest X-ray 3 views | CPT 71047 | $152.63 |
| CT chest without contrast | CPT 71250 | $2,674.35 |
| CT chest with contrast | CPT 71260 | $4,132.01 |
| CT chest with and without contrast | CPT 71270 | $4,602.6 |
| MRI chest without contrast | CPT 71550 | $4,728.83 |
| MRI chest with and without contrast | CPT 71552 | $7,345.76 |
| Lumbosacral spine X-ray | CPT 72100 | $373.16 |
| CT cervical spine without contrast | CPT 72125 | $2,674.35 |
| CT thoracic spine without contrast | CPT 72128 | $2,674.35 |
| CT lumbar spine without contrast | CPT 72131 | $2,674.35 |
| MRI cervical spine without contrast | CPT 72141 | $4,728.83 |
| MRI thoracic spine without contrast | CPT 72146 | $4,728.83 |
| MRI lumbar spine without contrast | CPT 72148 | $4,728.83 |
| MRI lumbar spine with and without contrast | CPT 72149 | $4,728.83 |
| MRI cervical spine with and without contrast | CPT 72156 | $7,345.76 |
| MRI lumbar spine with contrast | CPT 72158 | $7,345.76 |
| CT pelvis without contrast | CPT 72192 | $2,674.35 |
| CT pelvis with contrast | CPT 72193 | $4,132.01 |
| Shoulder X-ray | CPT 73030 | $550.09 |
| Humerus X-ray | CPT 73060 | $277.39 |
| Hand X-ray 3 views | CPT 73130 | $407.33 |
| MRI upper extremity joint without contrast | CPT 73221 | $4,728.83 |
| Knee X-ray 1-2 views | CPT 73560 | $237.41 |
| Ankle X-ray 3 views | CPT 73610 | $152.63 |
| MRI lower extremity joint without contrast | CPT 73721 | $4,728.83 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,728.83 |
| CT abdomen without contrast | CPT 74150 | $2,674.35 |
| CT abdomen with contrast | CPT 74160 | $4,132.01 |
| CT abdomen with and without contrast | CPT 74170 | $4,602.6 |
| CT abdomen and pelvis without contrast | CPT 74176 | $4,011.53 |
| CT abdomen and pelvis with contrast | CPT 74177 | $6,198 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $6,903.9 |
| MRI abdomen without contrast | CPT 74181 | $4,728.83 |
| Abdominal ultrasound complete | CPT 76700 | $848.06 |
| Abdominal ultrasound limited | CPT 76705 | $734.14 |
| Retroperitoneal ultrasound complete | CPT 76770 | $765.64 |
| Transvaginal ultrasound | CPT 76830 | $496.65 |
| Pelvic ultrasound complete | CPT 76856 | $848.06 |
| Scrotal ultrasound | CPT 76870 | $335.1 |
| EKG tracing only | CPT 93005 | $261.79 |
| Transthoracic echocardiogram complete | CPT 93306 | $797.78 |
| Transthoracic echocardiogram | CPT 93307 | $797.78 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $63,190 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $33,106 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $23,220 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $39,377 |
| COPD w MCC | MS-DRG 190 | $31,746 |
| COPD w CC | MS-DRG 191 | $31,746 |
| COPD w/o CC/MCC | MS-DRG 192 | $31,746 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $25,911 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $23,220 |
| AMI discharged alive w MCC | MS-DRG 280 | $39,829 |
| AMI discharged alive w CC | MS-DRG 281 | $31,027 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $23,220 |
| Heart failure & shock w MCC | MS-DRG 291 | $37,381 |
| Heart failure & shock w CC | MS-DRG 292 | $26,543 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $23,220 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $40,669 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $23,220 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $23,220 |
| GI hemorrhage w CC | MS-DRG 378 | $31,027 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $31,027 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $30,429 |
| Fractures of femur w/o MCC | MS-DRG 533 | $35,238 |
| Kidney/UTI w MCC | MS-DRG 689 | $30,692 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $22,832 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $41,238 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $27,631 |
| Basic metabolic panel (BMP) | CPT 80048 | $336.94 |
| Electrolyte panel | CPT 80051 | $213.56 |
| Comprehensive metabolic panel | CPT 80053 | $439.46 |
| Lipid panel | CPT 80061 | $175.76 |
| Renal function panel | CPT 80069 | $429.34 |
| Hepatic function panel | CPT 80076 | $281.44 |
| Urinalysis automated | CPT 81003 | $58.84 |
| Glucose quantitative | CPT 82947 | $313.91 |
| Hemoglobin A1c | CPT 83036 | $110.4 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $164.85 |
| Complete blood count with automated differential | CPT 85025 | $101.78 |
| Complete blood count without differential | CPT 85027 | $104.78 |
| Urine culture bacterial | CPT 87086 | $173.29 |
| Urine culture identification | CPT 87088 | $898.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $368.06 |
| Upper GI endoscopy diagnostic | CPT 43235 | $3,091.73 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,459.17 |
| Sigmoidoscopy diagnostic | CPT 45330 | $866.25 |
| Sigmoidoscopy with biopsy | CPT 45331 | $866.25 |
| Colonoscopy diagnostic | CPT 45378 | $2,944.54 |
| Colonoscopy with biopsy | CPT 45380 | $1,237.5 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $61,320 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $31,027 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $31,027 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $35,238 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $35,238 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $34,932 |
| Major joint replacement w MCC | MS-DRG 469 | $61,320 |
| Major joint replacement w/o MCC | MS-DRG 470 | $33,106 |
| Laparoscopic cholecystectomy | CPT 47562 | $18,986 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $33,106 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $33,106 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $33,106 |
| OR procedure for obesity w MCC | MS-DRG 619 | $63,521 |
| OR procedure for obesity w CC | MS-DRG 620 | $46,086 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $33,106 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $61,320 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $61,320 |
