| Psychoses | MS-DRG 885 | $12,859 |
| ED visit level 1 | CPT 99281 | $292.5 |
| ED visit level 2 | CPT 99282 | $414.4 |
| ED visit level 3 | CPT 99283 | $671.88 |
| ED visit level 4 | CPT 99284 | $1,118.4 |
| ED visit level 5 | CPT 99285 | $2,048.18 |
| Critical care, first hour | CPT 99291 | $2,759.58 |
| CT head without contrast | CPT 70450 | $1,681.84 |
| CT head with contrast | CPT 70460 | $1,509.69 |
| CT head with and without contrast | CPT 70470 | $1,850.66 |
| CT neck with contrast | CPT 70491 | $1,491.21 |
| MRI brain without contrast | CPT 70551 | $1,379.58 |
| MRI brain with contrast | CPT 70552 | $2,012.92 |
| MRI brain with and without contrast | CPT 70553 | $348.72 |
| Chest X-ray single view | CPT 71045 | $85.34 |
| Chest X-ray 2 views | CPT 71046 | $128.73 |
| Chest X-ray 3 views | CPT 71047 | $298.8 |
| CT chest without contrast | CPT 71250 | $1,365.1 |
| CT chest with contrast | CPT 71260 | $1,509.18 |
| CT chest with and without contrast | CPT 71270 | $2,014.98 |
| MRI chest without contrast | CPT 71550 | $2,135.65 |
| MRI chest with and without contrast | CPT 71552 | $2,916.17 |
| Lumbosacral spine X-ray | CPT 72100 | $353.9 |
| CT cervical spine without contrast | CPT 72125 | $1,473.23 |
| CT thoracic spine without contrast | CPT 72128 | $1,063.46 |
| CT lumbar spine without contrast | CPT 72131 | $1,506.1 |
| MRI cervical spine without contrast | CPT 72141 | $2,119.73 |
| MRI thoracic spine without contrast | CPT 72146 | $1,802.39 |
| MRI lumbar spine without contrast | CPT 72148 | $1,837.3 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,714.62 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,565.23 |
| MRI lumbar spine with contrast | CPT 72158 | $3,086.14 |
| CT pelvis without contrast | CPT 72192 | $1,027.52 |
| CT pelvis with contrast | CPT 72193 | $2,180.84 |
| Shoulder X-ray | CPT 73030 | $314.73 |
| Humerus X-ray | CPT 73060 | $276.26 |
| Hand X-ray 3 views | CPT 73130 | $295.01 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,100.2 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,624.02 |
| Knee X-ray 1-2 views | CPT 73560 | $252.72 |
| Ankle X-ray 3 views | CPT 73610 | $85.34 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,167.69 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,884.45 |
| CT abdomen without contrast | CPT 74150 | $969.49 |
| CT abdomen with contrast | CPT 74160 | $1,686.85 |
| CT abdomen with and without contrast | CPT 74170 | $1,809.06 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,746.93 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,262.48 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,160.08 |
| MRI abdomen without contrast | CPT 74181 | $1,669.39 |
| MRI abdomen with and without contrast | CPT 74183 | $2,918.74 |
| Abdominal ultrasound complete | CPT 76700 | $773.85 |
| Abdominal ultrasound limited | CPT 76705 | $729.12 |
| Retroperitoneal ultrasound complete | CPT 76770 | $579.23 |
| Obstetric ultrasound first trimester | CPT 76801 | $475 |
| Obstetric ultrasound after first trimester | CPT 76805 | $593.1 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $690.97 |
| Transvaginal ultrasound | CPT 76830 | $734.38 |
| Pelvic ultrasound complete | CPT 76856 | $626.47 |
| Scrotal ultrasound | CPT 76870 | $829.44 |
| Diagnostic mammography unilateral | CPT 77065 | $404.86 |
| Screening mammography bilateral | CPT 77067 | $407.03 |
| EKG tracing only | CPT 93005 | $167.14 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,573.75 |
| Transthoracic echocardiogram | CPT 93307 | $1,275.02 |
| Stress echocardiogram | CPT 93350 | $2,416.52 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $27,744 |
| COPD w MCC | MS-DRG 190 | $19,164 |
| COPD w CC | MS-DRG 191 | $15,896 |
| COPD w/o CC/MCC | MS-DRG 192 | $15,693 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $16,138 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $13,551 |
| AMI discharged alive w MCC | MS-DRG 280 | $24,702 |
| AMI discharged alive w CC | MS-DRG 281 | $18,822 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $21,874 |
| Heart failure & shock w MCC | MS-DRG 291 | $21,010 |
| Heart failure & shock w CC | MS-DRG 292 | $22,957 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,942.75 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $25,548 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $17,207 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $14,766 |
| GI hemorrhage w CC | MS-DRG 378 | $21,910 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $15,586 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $15,656 |
| Kidney/UTI w MCC | MS-DRG 689 | $21,437 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $16,828 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $30,691 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $22,993 |
| Basic metabolic panel (BMP) | CPT 80048 | $233.05 |
| General health panel | CPT 80050 | $603.48 |
| Electrolyte panel | CPT 80051 | $175.91 |
| Comprehensive metabolic panel | CPT 80053 | $312.66 |
| Lipid panel | CPT 80061 | $117.49 |
| Renal function panel | CPT 80069 | $165.64 |
| Hepatic function panel | CPT 80076 | $152.8 |
| Urinalysis non-automated | CPT 81002 | $22.47 |
| Urinalysis automated | CPT 81003 | $44.94 |
| Glucose quantitative | CPT 82947 | $57.14 |
| Hemoglobin A1c | CPT 83036 | $89.88 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $179.12 |
| Complete blood count with automated differential | CPT 85025 | $93.73 |
| Complete blood count without differential | CPT 85027 | $93.73 |
| Urine culture bacterial | CPT 87086 | $103.36 |
| Urine culture identification | CPT 87088 | $72.55 |
| Tissue exam by pathologist level IV | CPT 88305 | $289.62 |
| Fetal non-stress test | CPT 59025 | $540.66 |
| Vaginal delivery only | CPT 59409 | $2,962.95 |
| Office visit, new patient, 15-29 min | CPT 99202 | $175.24 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $248.5 |
| Office visit, new patient, 45-59 min | CPT 99204 | $335.39 |
| Office visit, new patient, 60-74 min | CPT 99205 | $332.87 |
| Office visit, established patient, 5 min | CPT 99211 | $90 |
| Office visit, established patient, 10-19 min | CPT 99212 | $120.03 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $167.79 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $165 |
| Office visit, established patient, 40-54 min | CPT 99215 | $209.18 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,863.71 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,863.71 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,812.11 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,812.11 |
| Colonoscopy diagnostic | CPT 45378 | $1,812.11 |
| Colonoscopy with biopsy | CPT 45380 | $2,343.79 |
| Colonoscopy with polyp removal | CPT 45385 | $2,343.79 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $86,856 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $69,353 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $49,409 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $43,431 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $35,518 |
