| Psychoses | MS-DRG 885 | $42,386 |
| ED visit level 1 | CPT 99281 | $68 |
| ED visit level 2 | CPT 99282 | $153.43 |
| ED visit level 3 | CPT 99283 | $282.41 |
| ED visit level 4 | CPT 99284 | $480.46 |
| ED visit level 5 | CPT 99285 | $1,371.9 |
| Critical care, first hour | CPT 99291 | $1,581.64 |
| CT head without contrast | CPT 70450 | $955.7 |
| CT head with contrast | CPT 70460 | $1,829.14 |
| CT neck with contrast | CPT 70491 | $1,483.37 |
| MRI brain without contrast | CPT 70551 | $3,587.21 |
| MRI brain with and without contrast | CPT 70553 | $3,012.4 |
| Chest X-ray single view | CPT 71045 | $145.01 |
| Chest X-ray 2 views | CPT 71046 | $210.52 |
| CT chest without contrast | CPT 71250 | $1,972.88 |
| CT chest with contrast | CPT 71260 | $2,327.13 |
| CT cervical spine without contrast | CPT 72125 | $1,182.75 |
| MRI cervical spine without contrast | CPT 72141 | $3,079.13 |
| CT pelvis with contrast | CPT 72193 | $1,806.88 |
| Humerus X-ray | CPT 73060 | $184.92 |
| Hand X-ray 3 views | CPT 73130 | $369.31 |
| Knee X-ray 1-2 views | CPT 73560 | $243.71 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,430.2 |
| CT abdomen with contrast | CPT 74160 | $2,065.16 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,214.98 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,094.14 |
| Abdominal ultrasound complete | CPT 76700 | $614.13 |
| Abdominal ultrasound limited | CPT 76705 | $668.74 |
| Retroperitoneal ultrasound complete | CPT 76770 | $552.08 |
| Pelvic ultrasound complete | CPT 76856 | $566.74 |
| Scrotal ultrasound | CPT 76870 | $552.08 |
| EKG tracing only | CPT 93005 | $164.9 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,794.14 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $61,024 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $30,658 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $20,768 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $47,420 |
| COPD w MCC | MS-DRG 190 | $33,613 |
| COPD w CC | MS-DRG 191 | $25,581 |
| COPD w/o CC/MCC | MS-DRG 192 | $19,481 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $24,455 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $19,072 |
| AMI discharged alive w MCC | MS-DRG 280 | $48,676 |
| AMI discharged alive w CC | MS-DRG 281 | $27,890 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $21,942 |
| Heart failure & shock w MCC | MS-DRG 291 | $38,957 |
| Heart failure & shock w CC | MS-DRG 292 | $25,763 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $17,175 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $36,535 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $22,325 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $17,178 |
| GI hemorrhage w CC | MS-DRG 378 | $29,759 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $19,129 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $23,657 |
| Fractures of femur w/o MCC | MS-DRG 533 | $47,572 |
| Kidney/UTI w MCC | MS-DRG 689 | $35,209 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $24,564 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $58,945 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $31,052 |
| Basic metabolic panel (BMP) | CPT 80048 | $241.26 |
| General health panel | CPT 80050 | $56.07 |
| Electrolyte panel | CPT 80051 | $120.42 |
| Comprehensive metabolic panel | CPT 80053 | $80.77 |
| Lipid panel | CPT 80061 | $14.6 |
| Renal function panel | CPT 80069 | $9.46 |
| Hepatic function panel | CPT 80076 | $8.91 |
| Urinalysis non-automated | CPT 81002 | $3.79 |
| Urinalysis automated | CPT 81003 | $2.45 |
| Glucose quantitative | CPT 82947 | $18.66 |
| Hemoglobin A1c | CPT 83036 | $10.58 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $161.76 |
| Complete blood count with automated differential | CPT 85025 | $87.77 |
| Complete blood count without differential | CPT 85027 | $73.99 |
| Urine culture bacterial | CPT 87086 | $80.56 |
| Urine culture identification | CPT 87088 | $38.8 |
| Tissue exam by pathologist level IV | CPT 88305 | $71.42 |
| Fetal non-stress test | CPT 59025 | $3,990 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $8,450 |
| Vaginal delivery only | CPT 59409 | $7,870 |
| Vaginal delivery with postpartum | CPT 59410 | $8,450 |
| Routine obstetric care with C-section | CPT 59510 | $8,450 |
| C-section delivery only | CPT 59514 | $7,870 |
| C-section with postpartum | CPT 59515 | $8,085 |
| Office visit, new patient, 15-29 min | CPT 99202 | $320 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $392 |
| Office visit, new patient, 45-59 min | CPT 99204 | $587.2 |
| Office visit, new patient, 60-74 min | CPT 99205 | $776 |
| Office visit, established patient, 5 min | CPT 99211 | $172.8 |
| Office visit, established patient, 10-19 min | CPT 99212 | $245.6 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $309.6 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $416 |
| Office visit, established patient, 40-54 min | CPT 99215 | $600.8 |
| Upper GI endoscopy diagnostic | CPT 43235 | $6,159 |
| Upper GI endoscopy with biopsy | CPT 43239 | $6,159 |
| Sigmoidoscopy diagnostic | CPT 45330 | $6,159 |
| Sigmoidoscopy with biopsy | CPT 45331 | $6,159 |
| Colonoscopy diagnostic | CPT 45378 | $6,159 |
| Colonoscopy with biopsy | CPT 45380 | $7,870 |
| Colonoscopy with polyp removal | CPT 45385 | $7,870 |
| Total shoulder arthroplasty | CPT 23472 | $13,958 |
| Hip hemiarthroplasty | CPT 27125 | $8,894 |
| Total hip replacement | CPT 27130 | $13,958 |
| Total knee replacement | CPT 27447 | $15,055 |
| Knee revision arthroplasty single component | CPT 27486 | $13,958 |
| Knee revision arthroplasty all components | CPT 27487 | $13,958 |
| Shoulder arthroscopy with decompression | CPT 29826 | $5,749 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $13,958 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $8,894 |
| ACL reconstruction | CPT 29888 | $13,958 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $139,481 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $72,743 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $51,068 |
| CABG single arterial graft | CPT 33533 | $14,056 |
| CABG 2 arterial grafts | CPT 33534 | $14,056 |
| CABG 3 arterial grafts | CPT 33535 | $14,056 |
| CABG 4+ arterial grafts | CPT 33536 | $14,056 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $51,332 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $41,445 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $103,388 |
| Open appendectomy | CPT 44950 | $8,894 |
| Laparoscopic appendectomy | CPT 44970 | $11,838 |
| Major joint replacement w MCC | MS-DRG 469 | $92,042 |
| Major joint replacement w/o MCC | MS-DRG 470 | $58,532 |
| Laparoscopic cholecystectomy | CPT 47562 | $11,838 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $11,838 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $88,374 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $63,558 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $49,493 |
| Lap inguinal hernia repair | CPT 49650 | $11,838 |
| Total abdominal hysterectomy | CPT 58150 | $11,655 |
| Vaginal hysterectomy | CPT 58260 | $10,948 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $11,838 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $15,055 |
| Lap salpingo-oophorectomy | CPT 58661 | $11,838 |
| OR procedure for obesity w MCC | MS-DRG 619 | $87,618 |
| OR procedure for obesity w CC | MS-DRG 620 | $48,561 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $45,772 |
| Complex cataract surgery | CPT 66982 | $7,870 |
| Cataract surgery with lens implant | CPT 66984 | $7,870 |
| Intravitreal injection | CPT 67028 | $5,749 |
| Vitrectomy mechanical | CPT 67042 | $10,948 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $37,649 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $62,180 |
| PCI single major coronary artery | CPT 92920 | $18,060 |
| PCI with drug-eluting stent | CPT 92928 | $18,060 |
| PCI bypass graft | CPT 92937 | $18,060 |
| Left heart catheterization | CPT 93452 | $13,913 |
| Coronary angiography with cath | CPT 93455 | $13,913 |
| Coronary angiography with bypass cath | CPT 93458 | $13,913 |
