| Psychoses | MS-DRG 885 | — |
| Psychotherapy 30 minutes | CPT 90832 | $161.83 |
| Psychotherapy 60 minutes | CPT 90837 | $166.69 |
| ED visit level 1 | CPT 99281 | $1.21 |
| ED visit level 2 | CPT 99282 | $49.19 |
| ED visit level 3 | CPT 99283 | $5,856.57 |
| ED visit level 4 | CPT 99284 | $1,381.5 |
| ED visit level 5 | CPT 99285 | $779.31 |
| Critical care, first hour | CPT 99291 | $34.2 |
| CT head without contrast | CPT 70450 | $47.16 |
| CT head with contrast | CPT 70460 | $232.69 |
| CT head with and without contrast | CPT 70470 | $8.4 |
| CT neck with contrast | CPT 70491 | $3,519.23 |
| MRI brain without contrast | CPT 70551 | $33,358 |
| MRI brain with contrast | CPT 70552 | $163.81 |
| MRI brain with and without contrast | CPT 70553 | $159.04 |
| Chest X-ray single view | CPT 71045 | $81.73 |
| Chest X-ray 2 views | CPT 71046 | $122.59 |
| Chest X-ray 3 views | CPT 71047 | $81.73 |
| CT chest without contrast | CPT 71250 | $72 |
| CT chest with contrast | CPT 71260 | $51.98 |
| CT chest with and without contrast | CPT 71270 | $12 |
| MRI chest without contrast | CPT 71550 | $45,644 |
| MRI chest with contrast | CPT 71551 | $736.18 |
| MRI chest with and without contrast | CPT 71552 | $345 |
| Lumbosacral spine X-ray | CPT 72100 | $97.23 |
| CT cervical spine without contrast | CPT 72125 | $130.93 |
| CT thoracic spine without contrast | CPT 72128 | $130.93 |
| CT lumbar spine without contrast | CPT 72131 | $97.94 |
| MRI cervical spine without contrast | CPT 72141 | $222.44 |
| MRI thoracic spine without contrast | CPT 72146 | $223.53 |
| MRI lumbar spine without contrast | CPT 72148 | $223.53 |
| MRI cervical spine with and without contrast | CPT 72156 | $318.09 |
| MRI lumbar spine with contrast | CPT 72158 | $318.09 |
| CT pelvis without contrast | CPT 72192 | $98.18 |
| CT pelvis with contrast | CPT 72193 | $17,349 |
| Shoulder X-ray | CPT 73030 | $87.28 |
| Humerus X-ray | CPT 73060 | $298.58 |
| Hand X-ray 3 views | CPT 73130 | $87.52 |
| MRI upper extremity joint without contrast | CPT 73221 | $89.28 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $345 |
| Knee X-ray 1-2 views | CPT 73560 | $5.16 |
| Ankle X-ray 3 views | CPT 73610 | $202.38 |
| MRI lower extremity joint without contrast | CPT 73721 | $6,566.69 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $345 |
| CT abdomen without contrast | CPT 74150 | $398.03 |
| CT abdomen with contrast | CPT 74160 | $167.19 |
| CT abdomen with and without contrast | CPT 74170 | $39.59 |
| CT abdomen and pelvis without contrast | CPT 74176 | $217.55 |
| CT abdomen and pelvis with contrast | CPT 74177 | $159.04 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $324.45 |
| MRI abdomen without contrast | CPT 74181 | $223.53 |
| MRI abdomen with and without contrast | CPT 74183 | $326.84 |
| Abdominal ultrasound complete | CPT 76700 | $152.7 |
| Abdominal ultrasound limited | CPT 76705 | $5.87 |
| Retroperitoneal ultrasound complete | CPT 76770 | $101.52 |
| Obstetric ultrasound first trimester | CPT 76801 | $162.25 |
| Obstetric ultrasound after first trimester | CPT 76805 | $97.94 |
| Transvaginal ultrasound | CPT 76830 | $98.18 |
| Pelvic ultrasound complete | CPT 76856 | $190.64 |
| Scrotal ultrasound | CPT 76870 | $129.2 |
| Diagnostic mammography unilateral | CPT 77065 | $114.49 |
| Diagnostic mammography bilateral | CPT 77066 | $142.88 |
| Screening mammography bilateral | CPT 77067 | $40.24 |
| EKG tracing only | CPT 93005 | $55.4 |
| Transthoracic echocardiogram complete | CPT 93306 | $630.18 |
| Transthoracic echocardiogram | CPT 93307 | $1,091.99 |
| Stress echocardiogram | CPT 93350 | $498.19 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | — |
| COPD w MCC | MS-DRG 190 | — |
| COPD w CC | MS-DRG 191 | — |
| COPD w/o CC/MCC | MS-DRG 192 | — |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | — |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | — |
| AMI discharged alive w MCC | MS-DRG 280 | — |
| AMI discharged alive w CC | MS-DRG 281 | — |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | — |
| Heart failure & shock w MCC | MS-DRG 291 | — |
| Heart failure & shock w CC | MS-DRG 292 | — |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | — |
| Cardiac arrhythmia w MCC | MS-DRG 308 | — |
| Cardiac arrhythmia w CC | MS-DRG 309 | — |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | — |
| GI hemorrhage w CC | MS-DRG 378 | — |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | — |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | — |
| Kidney/UTI w MCC | MS-DRG 689 | — |
| Kidney/UTI w/o MCC | MS-DRG 690 | — |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | — |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | — |
| Basic metabolic panel (BMP) | CPT 80048 | $12.53 |
| General health panel | CPT 80050 | — |
| Electrolyte panel | CPT 80051 | $7.47 |
| Comprehensive metabolic panel | CPT 80053 | $31.5 |
| Lipid panel | CPT 80061 | $18.29 |
| Renal function panel | CPT 80069 | $19.55 |
| Hepatic function panel | CPT 80076 | $16.34 |
| Urinalysis non-automated | CPT 81002 | $3.56 |
| Urinalysis automated | CPT 81003 | $81.73 |
| Glucose quantitative | CPT 82947 | $6.63 |
| Hemoglobin A1c | CPT 83036 | $616.73 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $24.88 |
| Complete blood count with automated differential | CPT 85025 | $9.94 |
| Complete blood count without differential | CPT 85027 | $9.59 |
| Urine culture bacterial | CPT 87086 | $11.96 |
| Urine culture identification | CPT 87088 | $8.62 |
| Tissue exam by pathologist level IV | CPT 88305 | $63.18 |
| Fetal non-stress test | CPT 59025 | $517 |
| Vaginal delivery only | CPT 59409 | — |
| C-section delivery only | CPT 59514 | — |
| Cesarean section w/o CC/MCC | MS-DRG 766 | — |
| Vaginal delivery w complicating dx | MS-DRG 774 | — |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | — |
| Office visit, new patient, 15-29 min | CPT 99202 | $1,025.78 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $128.16 |
| Office visit, new patient, 45-59 min | CPT 99204 | $363 |
| Office visit, new patient, 60-74 min | CPT 99205 | $251.76 |
| Office visit, established patient, 5 min | CPT 99211 | $264 |
| Office visit, established patient, 10-19 min | CPT 99212 | $109.73 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $2.73 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $479.93 |
| Office visit, established patient, 40-54 min | CPT 99215 | $464.85 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | — |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | — |
| Colonoscopy with biopsy | CPT 45380 | — |
| Colonoscopy with polyp removal | CPT 45385 | — |
| Total shoulder arthroplasty | CPT 23472 | — |
| Total hip replacement | CPT 27130 | — |
| Total knee replacement | CPT 27447 | — |
| Knee revision arthroplasty single component | CPT 27486 | — |
| Knee revision arthroplasty all components | CPT 27487 | — |
| Shoulder arthroscopy with decompression | CPT 29826 | — |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | — |
| Knee arthroscopy with meniscectomy | CPT 29881 | — |
| ACL reconstruction | CPT 29888 | — |
| Major small/large bowel procedures w MCC | MS-DRG 329 | — |
| Major small/large bowel procedures w CC | MS-DRG 330 | — |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | — |
| CABG single arterial graft | CPT 33533 | — |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | — |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | — |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | — |
| Open appendectomy | CPT 44950 | — |
| Laparoscopic appendectomy | CPT 44970 | — |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | — |
| Major joint replacement w MCC | MS-DRG 469 | — |
| Major joint replacement w/o MCC | MS-DRG 470 | — |
| Laparoscopic cholecystectomy | CPT 47562 | — |
| Lap cholecystectomy with cholangiography | CPT 47563 | — |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | — |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | — |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | — |
| Lap inguinal hernia repair | CPT 49650 | — |
| Total abdominal hysterectomy | CPT 58150 | — |
| Vaginal hysterectomy | CPT 58260 | — |
| Lap-assisted vaginal hysterectomy | CPT 58550 | — |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | — |
| Lap salpingo-oophorectomy | CPT 58661 | — |
| OR procedure for obesity w MCC | MS-DRG 619 | — |
| OR procedure for obesity w CC | MS-DRG 620 | — |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | — |
| Complex cataract surgery | CPT 66982 | — |
| Cataract surgery with lens implant | CPT 66984 | — |
| Intravitreal injection | CPT 67028 | — |
| Vitrectomy mechanical | CPT 67042 | — |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | — |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | — |
| PCI single major coronary artery | CPT 92920 | — |
| PCI with drug-eluting stent | CPT 92928 | $14.23 |
| PCI bypass graft | CPT 92937 | — |
| Left heart catheterization | CPT 93452 | — |
| Coronary angiography with cath | CPT 93455 | $2,803.36 |
| Coronary angiography with bypass cath | CPT 93458 | $3,147.96 |
